"Gluten-free prescribing is in a state of flux"

Consider this off-core-topic post an extension of previous other off-topic chatter on this blog talking about the prescription of gluten-free foods here in Blighty (see here). On that previous blogging occasion, I discussed a 'head-to-head' debate on whether the prescription of gluten-free foods for conditions such as coeliac disease was still 'relevant' in an age when supermarkets have shelves loaded with gluten-free products as part of a societal fascination with 'going gluten-free'. Whether there may be other models - such as the use of a voucher scheme - that could save time and money yet still ensure that the important use of a gluten-free diet in relation to coeliac disease is maintained and supported.

Well, the recent findings reported by Alex Walker and colleagues [1] add to this debate, and their look at "long-term national trends in gluten-free prescribing, and practice and Clinical Commissioning Group (CCG) level monthly variation in the rate of gluten-free prescribing (per 1000 patients) over time." CCGs by the way, are groups here in England "responsible for the planning and commissioning of health care services for their local area."

Walker et al relied on a retrospective cohort study design that analysed prescribing and spending data from various sources, and covered various geographical areas of England in relation to gluten-free prescribing. Alongside, other potentially pertinent data were included in the statistical mix, for example: "Index of Multiple Deprivation (IMD) score; patients with a long-term health condition (%); patients over 65 (%) and whether each practice is a ‘dispensing practice’ with an in-house pharmacy service (yes or no)."

Results: including data from over 7600 medical practices, authors reported that between July 2012 and June 2013, some 1.8 million prescriptions for gluten-free products were dispensed costing around £25.4 million. Fast forward to the period July 2016 - June 2017 and fewer prescriptions were made: "1.3 million gluten-free prescriptions nationally... with a total expenditure of £18.7 million." This, bearing in mind, that rates of diagnosed coeliac disease are seemingly only going in one direction - up [2].

Researchers also reported that there was "substantial variation in prescribing rates among practices" which was captured by some other reporting on the Walker paper as per bylines such as: "Prescribing of gluten-free products in England differs largely and “without good reason”, researchers have concluded." Indeed Walker and colleagues concluded that much of the geographical discrepancy in the gluten-free prescribing rates was "driven at the CCG level, where there is also a great deal of variation." For some CCGs, the decision was to provide gluten-free prescriptions; for others, there seems to be "a partial or complete withdrawal of prescriptions." A bit of a postcode lottery if you like.

As to those other variables included in the analysis, a few other important details emerged. So: "practices in the most deprived areas had a significantly lower rate of gluten-free prescribing than those in less deprived areas." Further: "We also found that percentage of patients over 65 is strongly associated with gluten-free prescribing, which is unsurprising given that coeliac disease prevalence increases with age." That first finding in relation to deprivation *might* be linked to things like an under-diagnosis of something like coeliac disease in those areas. But it could point to other factors potentially coming into play as well...

At the time of writing / publishing this post, we are still living in the age of austerity here in Blighty. Government in particular, [still] wants to 'balance the books' yet is still expecting national services such as health to provide for the population they serve. Set within that context, and also how health budgets are having to deal with more people with more complex needs, it's probably not surprising that for some geographical areas, 'low hanging fruit' such as gluten-free prescriptions are seen as fair game when it comes to balancing the books. It shouldn't, but there you go.

I do stand by the idea that if things are seemingly 'on the downward slide' in terms of gluten-free prescribing patterns, there may be other models to look at that could help (i.e. that voucher scheme idea). Patients and their relevant organisations need to have a voice in this process to ensure that gluten-free diets are maintained and health does not unduly suffer. Food, for people with coeliac disease - gluten-free food - is medicine, and one should never forget that and the absolute requirement to provide such medical provision.

To close, and entirely unrelated to today's post, I see Belgium have some historical and/or statistical advantage when it comes to the World Cup starting soon...

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[1] Walker AJ. et al. Trends, geographical variation and factors associated with prescribing of gluten-free foods in English primary care: a cross-sectional study. BMJ Open. 2018 Apr 16;8(3):e021312.

[2] Holmes GKT. & Muirhead A. Epidemiology of coeliac disease in a single centre in Southern Derbyshire 1958-2014. BMJ Open Gastroenterol. 2017 Apr 1;4(1):e000137.

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How much does it cost to assess a child for autism?

In answer to the question titling this post - 'How much does it cost to assess a child for autism?' - the results published by Mark Galliver and colleagues [1] provide some important findings, at least pertinent to the diagnostic experience here in Blighty.

Authors concluded that assessment for autism "typically takes 13 hours of professional time" and costs somewhere in the region of "£650–£1000 ($975–$1500) per child." Importantly too, the staff costs of around £800 per assessment do not cover "costs of intervention, parent psychological education, investigation and assessment and management of comorbidities."

I appreciate that talking about 'financial costs' associated with autism (assessment) is not a topic everyone will enjoy discussing. Much like other 'bean counter' discussions (see here and see here), everyone [rightly] aspires to providing this, that and t'other to improve facilities with regards to diagnosis and indeed, post-diagnostic services. The financial reality however, particularly in these days of continued austerity, is that such services are often under-funded, under-resourced and headlines including words like 'two year wait' for diagnostic assessment (see here) are not uncommon. People rightly get angry about this but the services themselves and the people delivering them are not to blame.

Galliver et al started out with some important premises. First, there are a growing number of referrals for assessment for autism. Second, such an 'increase in demand' naturally puts greater pressure on diagnostic services resulting in longer waiting times. Third, there are recognised pathways for referral and assessment for autism, but the resourcing of such pathways might not always be optimal either in form or amount. All of this is set in the context of the National Health Service (NHS) providing clinical and medical services here in the UK, free at the point of need and all that.

Researchers therefore decided to ask various local child development centres (CDC) in England about their diagnostic experiences in terms of resources and costs. Various questions were asked pertinent to the pathway used to deliver assessments and professional time typically allocated to said assessments. They report on responses from 60% of the CDC - no, not that CDC - initially questioned, covering a range of services in different geographic locations.

I don't need to rehash the financial findings again. I will however mention a couple of associated points that might be relevant. First, autism rarely exists in some sort of diagnostic vacuum (see here). The authors make the point that their figures did not cover the "investigation and assessment and management of comorbidities" something important in these days of greater realisation of 'autism plus' and ESSENCE (see here). In this respect, the figures provided by Galliver are likely to be an underestimate of the true financial cost of assessment.

Second, the issue of growing numbers of referrals and "increasing demand" for diagnostic services is highlighted in various parts of the reported findings. I have my own opinions as to why this is happening (see here and see here) but the one thing that is becoming increasingly clear is that such an increase is probably not just due to better recognition of autism or issues such as diagnostic switching (see here and see here). Yes, these points were probably relevant about 10-20 years ago, but now, I'd have to say not as much as [clinical] awareness must have peaked by now. At some point the question of 'why the increase' is going to have to be properly faced up to if it's not going to be all about just assessing and diagnosing in a catch-up sense.

Finally, although more funding would help, such demands on assessment services are probably not going to be met by just 'throwing a few quid' at them. The NHS is moving with the times in other areas; and the rise and rise of technology to potentially assist with autism assessments is becoming increasingly important. I'm thinking about work such as that being done at the Duda-Wall laboratory (see here and see here) where technology such as machine learning is being used in the context of autism screening. And things like autism screening triage via YouTube (see here) *might* also [eventually] become more commonplace. Technology can potentially ease the burden on assessment services.

Whatever does or does not happen as a result of findings such as those by Galliver and colleagues, the underlying messages are that autism assessment is (a) not an inexpensive process and (b) either significant funds need to be poured into the service or services need a revamp on the basis of current funding schedules and as national finances allow. Either way, I don't see assessment waiting times improving much in the near future despite the important work provided by our fantastic NHS and the desperate need for timely autism assessment.

And I've not even mentioned about adult diagnostic services...

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[1] Galliver M. et al. Cost of assessing a child for possible autism spectrum disorder? An observational study of current practice in child development centres in the UK. BMJ Paediatr Open. 2017 Nov 30;1(1):e000052

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Sick leave and income levels for parents of children with autism

"Parents of children with ASD [autism spectrum disorder] living in Stockholm, Sweden in 2006 were more likely to be on sick leave, not in the labor force, or earning low income when compared to parents who did not have a child with ASD and these results remained after adjusting for familial socioeconomic factors and parental psychiatric care."

That was the rather grim conclusion reached by Miranda McEvilly and colleagues [1] (open-access) following their analysis of families taking part in the Stockholm Youth Cohort (SYC) initiative [2] - "a record-linkage study comprising all individuals aged 0–17 years, ever resident in Stockholm County in 2001–2007 (N = 589,114)." From the huge number of participants, researchers identified 2,982 mothers/fathers with a child diagnosed on the autism spectrum: "1,207 had ASD with ID [intellectual disability] (or more than one child with ASD where at least one of the children had ASD with ID) and 1,685 had ASD without ID."

"Four outcomes, two for sick leave and two for work participation, were obtained using data from LISA in 2006." LISA by the way, refers to "the longitudinal integration database for health insurance and labor market studies (LISA)" based in Sweden and carries quite a bit of information about employment and related parameters. Participant data were analysed according to the presence of offspring autism and whether or not said autism was accompanied by ID or not. Various potential confounding variables were also added into the statistical mix as per the headline sentence above.

Results: well, we already know that parents with a child (or children) with autism were quite a bit more likely to be taking sick leave or not to be in work or to be on a low income compared to those without. This trend was particularly notable in mothers of children with autism. Researchers also reported that when comparing families with a child with autism and ID with those with a child with autism but no ID, several differences were also apparent. So: "Increased sick leave (15–365 days) is associated with parents of children with ASD without ID but not ASD with ID" (again, with mothers faring worse than fathers).

"Parents who have a child with ASD are more likely to experience stress, depression, and fatigue. Therefore it is not surprising that these parents take sick leave more frequently or participate less in the work force." As per this excerpt, the authors frame their findings within the perspective that parenting a child diagnosed with an ASD can carry its own particular stresses and strains outside of those more generally associated with parenting. I've covered this topic before on this blog and how, without blaming or stigmatising, there is a growing recognition of the need for additional support services for those parents (see here). The fact that Sweden has specific policies "aimed at helping families of children with ASD, both with well-being and with ability to work" also seemed not to be as effective as perhaps initially thought as "these parents remain a vulnerable group for which additional support might be warranted."

This is valuable data that adds to previous discussions about how the presence of familial autism can [variably] impact well beyond individuals and contribute to some of the societal inequalities that have been noted. One might quibble with some of the study mechanics such as the inclusion of "parents with children with other disabilities" in the comparison group or the lack of emphasis on other autism-associated comorbidities (in these days of ESSENCE) outside of ID and how they may impact on parental employment and earnings, but this is perhaps research fodder for a different time.

"It can also be noted that being on sick leave, outside of the work force or earning a low income will have long reaching impact on these parents because of Sweden’s pension system which is based on an individual’s life time earnings." This is another potential outcome that the authors focus in on as a consequence of their findings. One might put forward the viewpoint that where noted both inside and outside of Sweden, further preferential economic policies could be put in place as and when a child is diagnosed to secure both their future and that of their parents too. Also: "It is recommended that further studies be done to see what support mothers and fathers would find most beneficial and what support they are lacking." I cannot disagree with that last sentiment.

Music: David Bowie - Five Years.

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[1] McEvilly M. et al. Sick Leave and Work Participation Among Parents of Children with Autism Spectrum Disorder in the Stockholm Youth Cohort: A Register Linkage Study in Stockholm, Sweden. Journal of Autism and Developmental Disorders. 2015; 45: 2381.

[2] Idring S. et al. Autism Spectrum Disorders in the Stockholm Youth Cohort: Design, Prevalence and Validity. PLoS One. 2012; 7(7): e41280.

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McEvilly M, Wicks S, & Dalman C (2015). Sick Leave and Work Participation Among Parents of Children with Autism Spectrum Disorder in the Stockholm Youth Cohort: A Register Linkage Study in Stockholm, Sweden. Journal of autism and developmental disorders PMID: 25697737

The bean counters of autism (part 2)

Consider this post an update to my previous discussions on the economics of the autism spectrum disorders (ASDs) published a few years back (see here). The interest in 'what autism costs' from a monetary point of view has been rekindled following quite a bit of media discussion on the study by Ariane Buescher and colleagues [1] (open-access here) including a piece posted on the BBC website and a write-up in the Guardian newspaper with quite a sensational headline: Study says cost of autism more than cancer, strokes and heart disease. The Buescher paper concluded that there was a "substantial direct and indirect economic effect of ASDs". An accompanying editorial from Shattuck & Roux [2] on the Buescher paper is also worth a read too.

The main points from the Buescher paper are pretty visible in the paper and accompanying media, but include:

• The estimated lifetime costs of supporting someone with autism and accompanying learning disability (intellectual disability) comes in at about £1.5 million here in the UK and $2.4 million in the United States. For those with no accompanying learning disability, the costs are estimated at £900,000 in the UK and $1.4 million in the US.
• The total estimated cost of autism in the UK is roundabout £32bn per year mostly associated with adult costs. Indeed, with only £3bn of that £32bn estimated to be directed to children with autism, there is a rather large gap very much apparent, bearing in mind that "individual productivity loss" (lost employment) made up a sizable proportion of the adult cost estimate. This is a hot topic in autism at the moment.
• Medical costs also get a mention and the fact that: "Medical costs were much higher for adults than for children".
• Some discussion is also made of the amount of money dedicated to autism research. The Guardian report on this paper notes: "In the UK, £4m per year is spent on autism research, compared to £590m on cancer, £169m on heart disease and £32m on stroke research". I have to say that I'm not a great believer in making such comparisons given that there is quite a difference between something like autism and what falls under the heading of heart disease or cancer for example. Although perhaps placing a person at some [variable] increased risk of early mortality through comorbidity or the issue of wandering, autism is not for example, generally a life-limiting condition as the other diagnoses can sometimes be. Nevertheless, £4m spent annually on autism research here in the UK is a meagre sum; about the same as some football (soccer) transfers if I were to use another comparator.

There is always a danger that such studies of finances risk stigmatising a condition and resigning individuals - the many faces behind these figures - merely to statistics. In these days of continued austerity, the sum of £32bn is no small amount but one has to be slightly cautious about the figures arrived at (mostly estimates) and in what context such sums of money are used. I can speak from seeing one of the adult services available here in the UK that costs can be high but these are often offset against providing educational, residential and medical services which can very much positively impact on a person and their quality of life, and by proxy, the extended family too. Parents, siblings and other family members are more often than not tax payers (and voters!), and in the spirit of at least one arm of our welfare system here in the UK: availability from cradle to the grave and free at the point of need (see here) are important concepts to bear in mind.

I note that the inequality in autism research vs. autism services spending has already surfaced in some of the discussions on the Buescher paper. An "unacceptable imbalance" is the way one commentator put it complete with stark comparison of research spend vs. services spend. My mind wanders back to the recent Pellicano paper on autism research priorities here in the UK (see here) and how the identified goal of research making a difference to day-to-day life figured so heavily in that consultation. Again, I think we have to be a little bit cautious here in terms of the aims and objectives of autism research and the territory where such discussions can potentially head into. I would like to think that alongside the noble sentiments of a research agenda making an impact on day-to-day living, the Buescher findings might also open up wider discussions about things like the notion of plural autisms and onwards how research could better start taking into account factors like best responders to certain interventions. One might also think that a greater focus on differing developmental trajectories including those 'optimal outcomers' would be more forthcoming if one truly wanted to see how autism may not necessarily just be defined by an economic cost or financial burden.

"Parental productivity loss" is also mentioned in the paper, and an important concept this is too. Other media pieces on the Buescher paper talk about the effect of caring for a child or children with autism, and how jobs and careers are sometimes left behind [3]. I don't say this to further stigmatise or apportion blame, but the reality is that for some parents, quite a few parents [4], quitting employment in order to care for a child/adult happens and happens often. This can have obvious financial effects on the family and perhaps just as important, might also influence issues like stress levels too.

There is little more to say about the Buescher study and it's implications. I would perhaps reiterate that whilst the headlines of this study talk about counting costs and the "search for effective interventions that make best use of scarce societal resources", one should not lose sight of the fact that behind the figures and sums are real people and real families often struggling with severe financial hardship on top of various other challenges. I do believe that as a society we are becoming better at helping those with autism and their families to live rich and rewarding lives but would prefer not to see too many more studies just boiling autism down to an economic cost.

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[1] Buescher AVS. et al. Costs of Autism Spectrum Disorders in the United Kingdom and the United States. JAMA Pediatrics. 2014. June 9.

[2] Shattuck PT. & Roux AM. Autism: Moving Toward an Innovation and Investment Mindset. JAMA Pediatrics. 2014. June 9.

[3] Montes G. & Halterman JS. Child care problems and employment among families with preschool-aged children with autism in the United States. Pediatrics. 2008 Jul;122(1):e202-8.

[4] Ouyang L. et al. A comparison of family financial and employment impacts of fragile X syndrome, autism spectrum disorders, and intellectual disability. Res Dev Disabil. 2014 Jul;35(7):1518-27.

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Ariane V. S. Buescher, Zuleyha Cidav, Martin Knapp, & David S. Mandell (2014). Costs of Autism Spectrum Disorders in the United Kingdom and the United States JAMA Pediatrics : 10.1001/jamapediatrics.2014.210

Autism and residential placement

It's going to be a bit of an odd blog post this one as I muse over the results reported by McGill & Poynter* on the cost of residential placement for those diagnosed with an intellectual disability (ID). Odd because I'm going to be bringing in a little bit of politics - or at least UK Government legislation - and how this intersects with current financial policy. Hopefully you'll stay tuned though as I try and remain true to the aims of this blog (autism research and other musings).

I can't say I know a great deal about the provision of residential services for people with IDs. Through some contact with a local provider of such services for young people and older adults with autism, I've picked up snippets of what's involved and indeed the various processes and red-tape to be taken on board. All I'll say is that it's not as easy as you might think and indeed neither should it be in light of recent events at Winterbourne View here in the UK.

The McGill paper details a few important things:

• The aim of the study was to determine which factors most strongly contribute to the highest financial costs of placements for people with an ID.
• Bearing in mind the study was conducted in probably the most expensive part of the UK to live and work (South-East England), the average placement was estimated to cost £172,000 per year (about US$275,000). 
• To quote: "Young, male adults with learning disability, challenging behaviour and/or autism continue to receive very high cost residential support, often in out-of-area residential care". This was indicative of the fact that (a) quite a few people with IDs cannot be readily cared for in their own home, (b) indeed quite a few people with IDs can't even be cared for in the vicinity of where they were born and/are normally resident, and (c) part of the reason why residential placement is provided is because of the presence and impact of challenging behaviours (often with autism as a diagnosis). This last point on the impact of challenging behaviours fits quite well into the findings of Hodgetts and colleagues** (thanks Natasa) and how one facet of challenging behaviours in cases of autism, aggression, can have profound effects on families and caregivers (the possible causes of such aggression have been debated in a previous post).

This is not the first time that such provision has been the topic of scientific investigation as per papers like this one from Allen and colleagues*** who seemed to have arrived at similar conclusions with regards to the factors influencing the use of out-of-area residential care (autism, challenging behaviours). I don't think that this is a big surprise to anyone really - the more complicated and severe the presentation of symptoms, the greater the need for specialist, residential care and onward the higher the costs in order to provide that care. This outside of issues like aging and the question that no parent really wants to think about: what happens to my child when I'm gone?

I did say that I would bring a little politics into this post and so I am by introducing some of the provisions of the UK Autism Act 2009. I've briefly touched upon the Autism Act in previous posts (see here for example) and how as well as being the first ever disability-specific legislation in the UK, the Act road-maps what the State must offer for adults with autism including: (i) an assessment of needs, (ii) transition planning from childhood to adulthood, and (iii) planning in relation to the provision of relevant services.

It all sounds pretty good doesn't it? That and the changes to UK/English SEN provision, now (or soon) enabling parents to have a far greater say in how budgets for their child are spent and also getting rid of the cliff-edge that was being 16-years of age where services now stretch up to the age of 25 years for those in further education. Looking at all this on paper, I actually am very proud that old Blighty is taking a lead on these issues.

Not to rain on the parade however, but legislation and Politicians talking the talk is one thing, practical implementation and ensuring the funds are available to fulfil promises and commitments is another. Indeed a few stories in the press quite recently seem to unravel the purposes of why these policies have been set up. So this article in TES magazine paints a rather different picture of transition, and this article in the Guardian on what might potentially happen to specialist FE colleges in this brave new world. Indeed even some of the service providers are battling under-funding issues as per this fairly recent story (something I've heard about before). Of course I don't need to remind anyone about the current financial climate we are all faced with and for viewers (hopefully) reading this in 2020 or 2030, it is currently all rather messy. Councils and local authorities are cutting back and at the same time having to hold services and even improve them. Rather them than me.

What's the take home message from this post? Well, as per other posts, and without trying to turn people into statistics, autism costs in terms of provision and care, and the more challenging the presentation, the more the costs rise. Here in the UK we're doing pretty well in terms of legislation and getting the rules and regulations more into line with how the real world looks where autism is concerned and trying to ensure that particularly those with very complex needs are appropriately catered for by the State. I actually know a few families who have already put things like the Autism Act to good use with their children's future in mind. That being said, there seem like there are enough loop-holes (if I can use that term) present so that things still don't necessarily run smoothly when planning transition and specialist care if and when required.

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* McGill P. & Poynter J. High cost residential placements for adults with intellectual disabilities. J Appl Res Intellect Disabil. 2012; 25: 584-587.

** Hodgetts S. et al. Home sweet home? Families’ experiences with aggression in children With autism spectrum disorders. Focus Autism Other Dev Disabl. January 2013.

*** Allen DG. et al. Predictors, costs and characteristics of out of area placement for people with intellectual disability and challenging behaviour. J Intellect Disabil Res. 2007; 51: 409-416.

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McGill P, & Poynter J (2012). High cost residential placements for adults with intellectual disabilities. Journal of applied research in intellectual disabilities : JARID, 25 (6), 584-7 PMID: 23055291

The bean counters of autism

Good economic management is an absolute prerequisite for any business. Formulating an accurate business plan, projecting income and expenditure and eventually balancing the books all makes for a healthy venture and the avoidance of future problems. I don't think anyone would disagree with these notions; not even when applied to businesses as large as Government and the various services it offers.

The thing about economics and finance when applied to 'people' services, such as health and social spending, is however that they can tend to resign people to mere statistics. Words like 'cost-benefit ratio' then start to be introduced as per what seems to be happening with childhood heart units here in the UK. I tend to get nervous when I see such words because people, individual statistics, then start getting grouped into larger statistics, which can in some cases lose sight of the individual and their individual needs.

A recent paper published by Barrett and colleagues* adds to what is a growing number of research looking at the economics of autism spectrum conditions. Coincidentally I happened to be reading this blog post asking the question: how expensive is autism? The author's answer, not cheap, but to coin a phrase 'you're worth it'.

Barratt et al considered the various services and wider societal costs of very young children with autism in the UK as part of the PACT consortium study (which unfortunately reported only limited benefit from their parent communication intervention). The figure they arrived at per child with autism ranged from about £53 - £1,116 per month, with an average of £430 or about $680 (US). This figure covered everything from contact with healthcare professionals and other hospital and community services. Interestingly some of the families of the 152 children included in the report received little statutory support.

Other papers have detailed similar economic analyses of autism. This paper for example looked at range of childhood developmental conditions and concluded that aside from severe cognitive impairment, the range of autistic conditions carried one of the more significant economic costs to the public sector. Similar studies have reported similar results (here and here). The 2001 paper by Järbrink & Knapp estimated a cost of £1 billion per year for autism here in the UK, although that was based on an assumed prevalence of 5 per 10,000 people!

There are some difficult questions to ask from this collected number crunching: the numbers of cases, availability of services throughout the lifetime, the financial effects on parents/caregivers, use of intervention and intervening to modify symptom presentation; made all the more difficult by the various 'austerity' measures that are starting to impact on everybody's life in these uncertain times. Unfortunately, questions aplenty, solutions seem to be in short supply.

To finish, I had the pleasure of seeing an updated, reformed version of Arthur 2 Stroke in South Shields a few days back so here is a blast from the past (happy birthday Jane & Geoff).

* Barrett B. et al. Service and wider societal costs of very young children with autism in the UK. JADD. November 2011.

The people effects of the financial crisis

One of my 'other musings' posts this one but I will perhaps mention autism as a sideline.

If 2008, 2009, 2010 and 2011 will be remembered for anything, it will be the words 'global economic crisis' and 'austerity measures' reflective of the situation that we all seem to have found ourselves in. Whether these words will be forever linked to 2012 and beyond... who knows? Not being an Economist or anything related, I'm not going to get all political and try and discuss why we are in this position; merely to note that we are where we are and lots and lots of people are suffering as a result.

Perhaps one of the most long-suffering peoples caught up in this crisis are the Greeks. I'm not talking about their Government and other institutions who have overseen successive periods of growth and spending (and spending!), but rather the average Joe or Jane (Costas and Maria in Greek-speak) who have seen cuts in wages, services and jobs. Timely that another general strike begins there today. Many people seem eager to opine as to why Greece was particularly sensitive to the economic crisis but the bottom line is that it is the masses who suffer; and in many cases, the most vulnerable. A touch of irony that 'crisis' is a word derived from Greek as no doubt Gus Portokalos in My Big Fat Greek Wedding would have told us.

A recent letter published in the Lancet addresses another side-effect of the financial crisis in Greece, indeed probably the most important side-effect, the health and wellbeing of the Nation. The letter by Kentikelenis and colleagues makes a few eye-catching points about how the economic crisis is now starting to impact on people's lives not just their bank accounts and livelihoods. I was drawn to a few things:

• The rates of unmet medical and dental care increased pre-crisis 2007 to mid-crisis 2009; although the reasons were not necessarily just because of the affordability of health care.
• Health outcomes have worsened as reported by the escalating suicide rate and also numbers of cases of HIV infection coinciding with increased drug abuse and prostitution. There are reliable reports of individuals deliberately exposing themselves to HIV to benefit from the economic and social measures in place.
• Alcohol consumption seems to have dropped and drink-driving offending rates have decreased.

One should perhaps bear in mind that the data presented by Kentikelenis et al is predominantly based on comparisons between 2007 and 2009 before the 'real' austerity measures associated with the economic crisis started to bite.

Other reports add to the dark clouds over health in Greece suggesting that mental health is also deteriorating in many more Greeks, possibly (probably!) tied into the country's financial problems. This piece in Time magazine suggests that more people are seeking the help of mental health practitioners, with waiting times increasing for consultations for things like anxiety and depression. It probably does not help to see that mental health and social services which people are becoming ever more reliant on, will themselves also be cut/suspended as part of the snowball of austerity measures being put in place.

With all the cuts on-going, the question of what is being done for autism-related services in Greece is also at the back of my mind. Having conversed (quite a few years ago) with several people and organisations in Greece with a link to autism, the attitudes and service provision pre-crisis could perhaps most reliably be described as 'developing' at that stage. With the various austerity measures coming into place, it is perhaps incumbent on the Greek Government to ensure that the social and financial gains made in the area of autism and mental health in general, are not seen as an easy money-saving target, alongside the realisation that the health of the Nation, physical and mental, is the health and future of Greece.

Now back to Joanna Lumley and happier memories of the Cradle of Modern Civilisation...

* Kentikelenis A. et al. Health effects of financial crisis: omens of a Greek tragedy. Lancet. October 2011.