The utility of functioning in predicting health service use by people with common mental disorders

Abstract

Background
Mental health services are under-resourced in countries around the world. It is essential therefore that the scarce resources are allocated fairly and efficiently. To facilitate this process, extensive knowledge of the variables associated with health service use (HSU) by people with mental disorders is required. As diagnoses and symptoms may not explain a large proportion of the variance in this HSU, there is a need to investigate the relevant associations of other variables. The term ‘functioning’ relates to physical and mental functions and the ability to undertake activities and participate in all of life. The studies described within this thesis were to determine the utility of functioning in predicting HSU by people with common mental disorders. It was hypothesised that functioning would have good utility in this prediction.

Methods
A systematic review was initially undertaken, followed by three empirical studies: one set in low- and middle-income countries (LMICs) and two within the English National Health Service (NHS).

Results
(1) Systematic Review: There is a lack of existing research into the association of functioning with HSU. The available evidence was mixed: three functioning variables (i.e. cognitive deficits, social withdrawal and activities of daily living) were significantly associated with HSU, but only in 55% of the assessments conducted on them.
(2) Cross-sectional study: For older people with depression living in LMICs (n=4,590), functioning was significantly associated with one HSU outcome (i.e. hospital admission) but not another (i.e. “any community HSU”).
(3) Historical cohort study: the seven functioning items from the HoNOS instrument were not associated with mental health service costs for patients with common mental disorders, over one year (n=1,343).
(4) Prospective cohort study: functioning predicted total NHS costs for patients with mood and anxiety disorders over a six month period (n=102).

Discussion
The mixed findings provide partial support for the hypothesised predictive ability of functioning. Narrow operationalisations of functioning evidently have limited utility in predicting HSU. However, the positive findings of the final study support the predictive ability of ‘multi-domain’ functioning. Multi-domain functioning information could therefore be useful for the formation of patient clusters within mental health payment systems.

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