title: Incremental health expenditure and lost days of normal activity for individuals with mental disorders: results from the São Paulo Megacity Study.
abstract: BACKGROUND
  With the recent increase in the prevalence of mental disorders in developing countries, there is a growing interest in the study of its consequences. We examined the association of depression, anxiety and any mental disorders with incremental health expenditure, i.e. the linear increase in health expenditure associated with mental disorders, and lost days of normal activity.
  
  
  METHODS
  We analyzed the results from a representative sample survey of residents of the Metropolitan Region of São Paulo (n = 2,920; São Paulo Megacity Mental Health Survey), part of the World Mental Health (WMH) Survey Initiative, coordinated by the World Health Organization and performed in 28 countries. The instrument used for obtaining the individual results, including the assessment of mental disorders, was the WMH version of the Composite International Diagnostic Interview 3.0 (WMH-CIDI 3.0) that generates psychiatric diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Statistical analyses were performed by multilevel generalized least squares (GLS) regression models. Sociodemographic determinants such as income, age, education and marital status were included as controls.
  
  
  RESULTS
  Depression, anxiety and any mental disorders were consistently associated with both incremental health expenditure and missing days of normal activity. Depression was associated with an incremental annual expenditure of R$308.28 (95% CI: R$194.05-R$422.50), or US$252.48 in terms of purchasing power parity (PPP). Anxiety and any mental disorders were associated with a lower, but also statistically significant, incremental annual expenditure (R$177.82, 95% CI: 79.68-275.97; and R$180.52, 95% CI: 91.13-269.92, or US$145.64 and US$147.85 in terms of PPP, respectively). Most of the incremental health costs associated with mental disorders came from medications. Depression was independently associated with higher incremental health expenditure than the two most prevalent chronic diseases found by the study (hypertension and diabetes).
  
  
  CONCLUSIONS
  The fact that individuals with mental disorders had a consistent higher health expenditure is notable given the fact that Brazil has a universal free-of-charge healthcare and medication system. The results highlight the growing importance of mental disorders as a public health issue for developing countries.
authors.affiliation: Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil. alexdiasporto@usp.br.
authors.forename: Alexandre Dias Porto
authors.initials: AD
authors.lastname: Chiavegatto Filho
authors.affiliation: Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil. wang.pang@hc.fm.usp.br.
authors.forename: Yuan-Pang
authors.initials: YP
authors.lastname: Wang
authors.affiliation: Department of Economics, School of Economics, Business Administration and Accounting, University of São Paulo, São Paulo, Brazil. campino@usp.br.
authors.forename: Antonio Carlos Coelho
authors.initials: AC
authors.lastname: Campino
authors.affiliation: Department of Business Administration, Fundação Getúlio Vargas, São Paulo, Brazil. Ana.Malik@fgv.br.
authors.forename: Ana Maria
authors.initials: AM
authors.lastname: Malik
authors.affiliation: Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil. mcviana@uol.com.br.
authors.forename: Maria Carmen
authors.initials: MC
authors.lastname: Viana
authors.affiliation: Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil. lhsgandr@usp.br.
authors.forename: Laura Helena
authors.initials: LH
authors.lastname: Andrade
mesh_terms: D000041:Absenteeism; D000203:Activities of Daily Living; D000328:Adult; D000368:Aged; D001007:Anxiety / Q000191:economics / Q000453:epidemiology; D001938:Brazil / Q000453:epidemiology; D003863:Depression / Q000191:economics / Q000453:epidemiology; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006306:Health Surveys / Q000706:statistics & numerical data; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D008297:Male; D001523:Mental Disorders / Q000191:economics* / Q000453:epidemiology*; D008603:Mental Health / Q000191:economics* / Q000706:statistics & numerical data*; D008875:Middle Aged; D015995:Prevalence; D014505:Urban Population / Q000706:statistics & numerical data; D055815:Young Adult