Ir Med J. 2007 Jul-Aug;100(7):518-21



Abstract
The “Cost of Disorders of the Brain in Europe” (CBDE) study was conducted by the European Brain Council (EBC) to estimate prevalence and cost of the twelve leading disorders encountered in Neurology, Neurosurgery, and Psychiatry. The data for Ireland are presented here. Prevalence and costing information was obtained by structured review of published literature for each country. Where such information was lacking, figures were estimated from European data. Costs included direct medical, direct non-medical, and indirect costs. None of the costs presented here are directly from Irish data and the prevalence figures are mostly estimated from known European rates. In 2004, 1.1 million people in Ireland were affected by a disorder of the brain. Total cost of included disorders in Ireland was 3.0 billion Euro, representing 3% of gross national product, and costing each Irish citizen € 775 per year. Brain disorders are prevalent and pose significant economic burden in Ireland.

Introduction
The European Brain Council (EBC) is a co-ordinating council formed by European organisations in psychiatry, neurology, neurosurgery, and basic neuroscience with representatives from the pharmaceutical industry. As its first major task, the EBC has analysed the burden and cost of brain disorders in Europe to inform decisions about initiatives in research, teaching and public awareness. Disorders of the brain (DoB) are viewed collectively by the EBC for this purpose and are not subdivided into neurological, neurosurgical, or psychiatric disorders.

The aim of the “Cost of Disorders of the Brain in Europe” (CBDE) study is to present best estimates of the cost of DoB across Europe based on the existing literature. The main results were published in June 2005 ¹. This paper reports data for Ireland from the CBDE study and discusses them in relation to the national literature.

Material and Methods
The methodology of the CBDE study has previously been detailed ¹. Twelve DoB were selected because they were believed to have the highest cost and because preliminary research indicated that at least some relevant data were present for these disorders. The disorders selected were: addiction, affective disorders, anxiety disorders, brain tumours, dementia, epilepsy, migraine and other headaches, multiple sclerosis, Parkinson’s disease, psychotic disorders, stroke and trauma. A group of leading European experts in the epidemiology of each disorder was appointed. Stockholm Health Economics were contracted to perform economic studies by the EBC. The epidemiology data used were based on systematic review of published epidemiological data in Europe, resourced from electronic databases (Medline and Web of Science) and complemented by national registries and the Internet. These have been published separately^2-9.

Twelve-month prevalence data were collected in all disorders by country and stratified according to age, gender and disorder severity where published evidence allowed it. When no data were available in a country, estimates were extrapolated from available data.

In parallel, the economists collected all available English language publications from Europe using Medline and HEED (Health Economic Evaluation Database). These data are presented in reviews published separately ^10-21. It was attempted to present all relevant costs including direct medical and non-medical costs, and indirect costs. So-called intangible costs such as suffering, loss of quality of life etc. have not been calculated. All economic data were transformed to €’s for 2004.

Results

Total prevalence
The total number of people with any DoB in the Republic of Ireland amounted to 1.1 million in 2004, corresponding to a quarter of the total number of Irish inhabitants. Estimates for mental disorders, migraine and epilepsy are based on the European patient populations aged 18-65. Estimates for dementia and Parkinson’s disease are limited to people over 65 years, and stroke to people over 25 years. Therefore this may underestimate prevalence for the population as a whole. Following correction for co-morbidity, still one fifth of the Irish population have a brain disorder.

Figure 1 Estimated number of cases of DoB in Ireland Note. The number of cases of stroke and trauma are based on incidence data in the lack of appropriate prevalence data in the literature.

The number of cases with addiction in Ireland totalled 74 000. This includes illicit drug and alcohol dependence, and excludes nicotine. Affective disorders totalled 198 000 cases and anxiety disorders 370 000. The most prevalent neurological disorder was migraine, with an estimated 335 000 cases (figure 1).

Cost per patient
Due to lack of economic studies within Ireland, the cost per case per disorder for 2004 are calculated for Ireland on the basis of economic data from other European countries (figure 2). Most costly per case are brain tumours and multiple sclerosis, which have a relatively low prevalence, whereas anxiety disorders and migraine, have a very low cost per case but are very prevalent.

Figure 2 Cost per case of specific brain disorders in Ireland (€PPP 2004)

Total cost of DoB
The total cost of all included DoB in Ireland was estimated at 3.0 billion Euros (figure 3). Affective disorders were the most costly DoB followed by addiction and anxiety disorders.

Figure 3 Total cost of brain disorders in Ireland (€PPP million, 2004)

Among the neurological disorders migraine was the most costly followed by epilepsy and stroke. Important cost categories are missing for several of the disorders. These include indirect costs and direct non-medical costs for psychotic disorders and trauma, and direct non-medical costs for anxiety disorders, brain tumours and affective disorders. The cost of stroke is based on incidence data and is therefore an underestimate. Table 1 displays the cost of DoB for each individual citizen in Ireland.

Total cost of DoB distributed by resource items
Direct health care cost amounted to €891 million and constituted 29% of total cost, direct non-medical cost totalled €456 million, 15%, and indirect cost €1.7 billion (56%) and was mainly because of production loss due to sick leave (Figure 4).

Figure 4 Distribution of total cost of DoB in Ireland by resource item components

Note. Direct non-medical costs are missing for the following disorders: affective disorders, anxiety disorders, migraine and trauma. Indirect cost is missing for psychotic disorder. Only indirect costs due to sick-leave were included in anxiety disorders.

Table 2 displays the cost of DoB allocated to their most relevant clinical specialty. Dementia is considered separately as this disorder is managed in practice by various disciplines including age-related health-care, psychiatry and neurology. The biggest neurosurgical disorder, herniated disc, was not included in our study. Brain disorders in Ireland constituted 12% of the total direct health care cost in Ireland. Out of total drug sales in Ireland, 8% were used for treatment of brain disorders.

Discussion
Overall, this study shows that brain disorders are both prevalent and costly within Ireland. They consume 3% of the gross national product and cost each citizen of Ireland € 775 per year. Disorders that are traditionally regarded as psychiatric account for approximately two thirds of the total costs while neurological and neurosurgical disorders account for another third. Highly prevalent disorders such as anxiety and migraine are inexpensive per case but, due to their high prevalence, are very costly to society. Affective disorders are the most costly DoB in Ireland because they are both prevalent and costly per case. This is in keeping with the general costing picture in Europe.

The results presented in this paper represent the breakdown of costs of DoB in Ireland as estimated from the CBDE project published last year [1]. It should be noted that the country-specific results from this project are uncertain for most disorders owing to the lack of structured epidemiological data and costing information available from each country. Ireland is no exception to this, and indeed for the costing of brain disorders in Ireland, there was no single cost study found in the literature for any specific DoB. Therefore the presented cost-estimates and prevalence figures for Ireland are reliant on transformation of data from other countries and likely incorporate over- as well as under-estimates for some disorders. Indeed a review of the limited prevalence data available from Ireland and of indirect measures of cost point to a number of discrepancies from the published European data as outlined below.

The presented data on costs of MS from the CBDE underestimate Irish cost by some 60%. This underestimate is based on use of old prevalence data that considered point prevalence for MS in Ireland to be 66/100.000. Most recent estimates in Ireland show a south-north gradient in MS prevalence from 120.7-184.6/100,000 ²³. The total cost of MS in the CBDE is estimated at 65 million Euro per annum. The true figure is closer to 150 million Euro, which is in line with the annual cost estimates for stroke and epilepsy.

The cost of addiction in Ireland is also conservatively estimated in the CBDE, reflecting both the lack of national data and the chosen definitions for addiction, which are often cultural. For alcohol addiction, a median figure of 2.4% has been applied to all European countries. There are certainly no national prevalence studies within Ireland but existing local surveys have suggested that one in ten Irish adults satisfy criteria for alcohol addiction ²⁴ For nicotine addiction, it was assumed that 30% of smokers are addicted which may also be too low.

In relation to costing, the data from the CBDE adjusted for Ireland appear to under-estimate the cost of drug treatment for brain disorders. This is evident from comparison with indirect measures of cost such as the published figures for General Medical Scheme (GMS) payments. The CBDE estimate for the cost of drugs in Ireland for neurologic disorders is 61million Euro per annum. The published Health Service Executive (HSE) data show that the cost of drugs, medicines and appliances to GMS patients is 150.83 million Euro (19.7% of GMS drugs budget), and that a further 52.94 million is paid by those availing of the Drugs Payment Scheme (DPS), and 12.4 million to those on the Long Term Illness Scheme (LTI). This represents a total of 216 million Euro, over three times the CBDE estimate ²⁵.

The publication of the CBDE is an important step in grasping the economic and social extent of the most common brain disorders. It serves as a useful framework for policy-makers within Europe. This paper presents the results of the CBDE in relation to Ireland and its costs. As practically all of the information is extrapolated and adjusted from other European data, the results can serve at best as a rough index rather than an accurate reflection. Their publication argues the need for properly resourced epidemiologic research in relation to DoB in Ireland to further refine the extrapolated estimates.

The CBDE data for Ireland provide food for thought. Most clearly they show that disorders of the brain are common, and expensive, not least in relation to preventable disorders such as addiction (annual costs of half a billion euros). The direct medical costs for brain disorders is relatively small when compared to their overall expense and indirect costs, indicating that resources might best be targeted at prevention and appropriate medical management in order to alleviate the overall cost burden to the state. In Ireland this would mean improved investment and structuring of Neurology, Neurosurgery, and Psychiatry services. Resources must also be directed towards structured epidemiological research in Ireland for these disorders so that planning of our health services may be adequately informed.

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