Cost-effectiveness of interventions for treating anxiety disorders: A systematic review

Health-Economic Evaluation of Psychological Interventions for Anxiety Prevention: A Systematic Review

OBJECTIVE

Although evidence supports the effectiveness of psychological interventions for prevention of anxiety, little is known about their cost-effectiveness. The aim of this study was to conduct a systematic review of health-economic evaluations of psychological interventions for anxiety prevention.

METHODS

PubMed, PsycInfo, Web of Science, Embase, Cochrane Central Register of Controlled Trials, EconLit, National Health Service (NHS) Economic Evaluations Database, NHS Health Technology Assessment, and OpenGrey databases were searched electronically on December 23, 2022. Included studies focused on economic evaluations based on randomized controlled trials of psychological interventions to prevent anxiety. Study data were extracted, and the quality of the selected studies was assessed by using the Consensus on Health Economic Criteria and the Cochrane risk-of-bias tool.

RESULTS

All included studies (N=5) had economic evaluations that were considered to be of good quality. In two studies, the interventions showed favorable cost-effectiveness compared with usual care groups. In one study, the intervention was not cost-effective. Findings from another study cast doubt on the cost-effectiveness of the intervention, and the cost-effectiveness of the intervention in the remaining study could not be established.

CONCLUSIONS

Although the findings suggest some preliminary evidence of cost-effectiveness of psychological interventions for preventing anxiety, they were limited by the small number of included studies. Additional research on the cost-effectiveness of psychological interventions for anxiety in different countries and populations is required.

Brief digital self-care intervention for health anxiety in a Swedish Medical University Clinic: a prospective single-group feasibility study

OBJECTIVES

In routine psychiatric care in Stockholm, Sweden, a comprehensive therapist-guided intervention for clinically significant health anxiety is implemented. However, there is a need for more easily accessible self-care interventions to improve treatment dissemination. This study aimed to transform an existing therapist-guided digital intervention into a self-care intervention, reducing patient burden and used clinical resources while maintaining quality and safety.

DESIGN

An uncontrolled feasibility study.

SETTING

Conducted at Karolinska Institutet, a medical university in Sweden, with nationwide recruitment trough online advertisements.

PARTICIPANTS

Twenty-five adults used the self-care intervention and underwent telephone assessments, along with completing self-rated questionnaires.

INTERVENTION

The newly developed 8-week self-care intervention was designed to be user-friendly without therapist guidance, and to facilitate high levels of behavioural engagement.

PRIMARY AND SECONDARY OUTCOME MEASURES

Indicators of quality and safety, including changes in health anxiety severity (primary), clinician time, participant adherence, perceived credibility/satisfaction with the intervention and adverse events, were benchmarked against a previous study of the more comprehensive intervention it was based on.

RESULTS

Compared with the original guided intervention, the self-care intervention was condensed in terms of text (up to 70% less reading), duration (8 weeks instead of 12) and number of exercises. Quality indicators were similar to the original version. Most participants worked actively with core components in the self-care intervention. Within-group effects on health anxiety from pretreatment to the 3-month follow-up were large (g=1.37; 95% CI 0.74 to 2.00). No serious adverse events were reported.

CONCLUSIONS

This brief digital self-care intervention shows potential for increasing access to treatment for individuals with health anxiety while reducing the burden on patients and clinical resources. Future studies should investigate the optimal type of intervention and support for different individuals, and if non-inferiority can be established.

TRIAL REGISTRATION NUMBER

NCT05446766.

Economic evaluations of electronic health interventions for people with age-related cognitive impairment and their caregivers: A systematic review

OBJECTS

Dementia has physical, social and economic impacts, causing considerable distress for people with age-related cognitive impairment (PWACI) and their caregivers. Electronic health (e-health) interventions can provide convenient education to improve the coping competence of caregivers and have become an important approach to supporting them. Understanding the economic evidence of e-health interventions will facilitate the decision making and implementation of integrating e-health into routine health services. The present review aimed to appraise economic evidence related to e-health interventions for PWACI and their caregivers.

METHODS

We systematically searched multiple cross-disciplinary databases from inception to February 28, 2023. Two reviewers independently selected the trials, assessed the quality, and checked the data. A descriptive-analytical narrative method was used to analyze the review findings.

RESULTS

Thirteen studies were analyzed, including 12 randomized controlled trials and one quasi-experimental study. All included studies were conducted in developed countries. The included studies reported limited economic information. There were six cost-effectiveness analysis, five cost-consequence analysis and one partial economic evaluation. The included studies were heterogeneous, and varied in quality. The results demonstrated that e-health multicomponent interventions can reduce the cost of health service utilization in short term (10-104 weeks).

CONCLUSIONS

Few studies calculated the incremental cost-effectiveness ratio to evaluate the cost-effectiveness of e-health interventions. Preliminary evidence indicates that e-health interventions can reduce the cost of health service utilization in the short term, but the cost-effectiveness of e-health interventions hasn't been identified. More robust evidence is needed to clarify the value of e-health interventions for PWACI and their caregivers.

Costs and cost-effectiveness of Shamiri, a brief, layperson-delivered intervention for Kenyan adolescents: a randomized controlled trial

BACKGROUND

Low- and middle-income countries (LMICs) have the highest socio-economic burden of mental health disorders, yet the fewest resources for treatment. Recently, many intervention strategies, including the use of brief, scalable interventions, have emerged as ways of reducing the mental health treatment gap in LMICs. But how do decision makers prioritize and optimize the allocation of limited resources? One approach is through the evaluation of delivery costs alongside intervention effectiveness of various types of interventions. Here, we evaluate the cost-effectiveness of Shamiri, a group- and school-based intervention for adolescent depression and anxiety that is delivered by lay providers and that teaches growth mindset, gratitude, and value affirmation.

METHODS

We estimated the cost-effectiveness of Shamiri using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines for economic evaluations. Changes in depression and anxiety were estimated using the Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder questionnaire (GAD-7) at treatment termination and 7-month follow-up using two definitions of treatment benefit. Cost-effectiveness metrics included effectiveness-cost ratios and cost per number needed to treat.

RESULTS

Base case cost assumptions estimated that delivering Shamiri cost $15.17 (in 2021 U.S. dollars) per student. A sensitivity analysis, which varied cost and clinical change definitions, estimated it cost between $48.28 and $172.72 to help 1 student in Shamiri, relative to the control, achieve reliable and clinically significant change in depression and anxiety by 7-month follow-up.

CONCLUSIONS

Shamiri appears to be a low-cost intervention that can produce clinically meaningful reductions in depression and anxiety. Lay providers can deliver effective treatment for a fraction of the training time that is required to become a licensed mental health provider (10 days vs. multiple years), which is a strength from an economic perspective. Additionally, Shamiri produced reliable and clinically significant reductions in depression and anxiety after only four weekly sessions instead of the traditional 12-16 weekly sessions necessary for gold-standard cognitive behavioral therapy. The school setting, group format, and economic context of a LMIC influenced the cost per student; however, broader conclusions about the cost-effectiveness of Shamiri have yet to be determined due to limited economic evaluations of mental health programs in LMICs.

TRIAL REGISTRATION

This study was registered prior to participant enrollment in the Pan-African Clinical Trials Registry (PACTR201906525818462), registered 20 Jun 2019, https://pactr.samrc.ac.za/Search.aspx .

Increased anxiety and stress-related visits to the Shanghai psychiatric emergency department during the COVID-19 pandemic in 2020 compared to 2018-2019

Background

The coronavirus disease 2019 (COVID-19) pandemic has had a significant and far-reaching impact on mental health. The psychiatric emergency department (PED) is pivotal in the management of acute and severe mental illnesses, especially anxiety-and stress-related disorders.

Aims

This study aimed to evaluate whether changes in the frequency or patients' demographics of visiting the PED occurred during the COVID-19 pandemic among individuals with anxiety and stress-related disorders.

Methods

This cross-sectional study used data on PED visit counts from the largest psychiatric hospital in China between 2018 and 2020 (before and during the COVID-19 pandemic). Data from 2020, representing the COVID-19 pandemic period, were extracted from electronic medical records and compared using descriptive statistics for the same periods in 2018 and 2019.

Results

The number of PED visits related to anxiety and stress disorders per year increased from 83 in 2018 to 136 (63.9% increase) in 2019 and 239 (188.0% increase) in 2020. Compared to that in 2018 and 2019, the proportion of PED visits in 2020 among patients with anxiety and stress disorders increased significantly. Patients with anxiety-and stress-related disorders during PED visits in 2020 were younger than those in 2018 and 2019 (three-year groups: F = 9.124, df = 2, p < 0.001).

Conclusion

Despite the epidemic-policy barriers against PED visits, PED care seeking has increased, thereby underscoring the need for crisis prevention services for patients with stress and anxiety disorders.

Systematic review of economic evaluations for internet- and mobile-based interventions for mental health problems

In view of the staggering disease and economic burden of mental disorders, internet and mobile-based interventions (IMIs) targeting mental disorders have often been touted to be cost-effective; however, available evidence is inconclusive and outdated. This review aimed to provide an overview of the cost-effectiveness of IMIs for mental disorders and symptoms. A systematic search was conducted for trial-based economic evaluations published before 10th May 2021. Electronic databases (including MEDLINE, PsycINFO, CENTRAL, PSYNDEX, and NHS Economic Evaluations Database) were searched for randomized controlled trials examining IMIs targeting mental disorders and symptoms and conducting a full health economic evaluation. Methodological quality and risk of bias were assessed. Cost-effectiveness was assumed at or below £30,000 per quality-adjusted life year gained. Of the 4044 studies, 36 economic evaluations were reviewed. Guided IMIs were likely to be cost-effective in depression and anxiety. The quality of most evaluations was good, albeit with some risks of bias. Heterogeneity across studies was high because of factors such as different costing methods, design, comparison groups, and outcomes used. IMIs for anxiety and depression have potential to be cost-effective. However, more research is needed into unguided (preventive) IMIs with active control conditions (e.g., treatment as usual) and longer time horizon across a wider range of disorders.Trial registration: PROSPERO Registration No. CRD42018093808.

A Pilot Feasibility Study of an Intensive Summer Day Camp Intervention for Children with Selective Mutism

Cost, scheduling, and implementation competency are barriers to accessing traditional evidence-based behavioral interventions for childhood selective mutism (SM). Brief, or intensive, interventions are a disruptive innovation to traditional therapy given the use of fewer sessions during a short-term time period. This study explored the acceptability, integrity, and effectiveness (i.e., single-case replicated AB design) of an intensive summer camp consisting of a 5-day behavioral therapy for 25 children with SM. Caregiver-rated treatment acceptability ratings and family interviews support intensive summer day camp as an acceptable intervention approach for SM. Additionally, results revealed that counselors and parents implemented SM behavioral therapy during camp with impressive integrity (>90%) after receiving training about SM behavioral therapy from an SM expert clinician. Effect size calculations of counselor-rated daily behavior ratings revealed reductions in anxiety during camp for 18 of the 25 campers. Significant caregiver-rated improvements in speaking behaviors were reported for 9 out of 14 campers with data available for analysis at the 3-month follow-up. This pilot feasibility study is the first to investigate intensive summer day camp as a treatment approach for SM and implications for future research are discussed.

Review: Economic evidence of preventive interventions for anxiety disorders in children and adolescents - a systematic review

BACKGROUND

Anxiety disorders are common in children and youth. Also, in prevention, be it universal, selective or indicated, economic evaluation supports decision-making in the allocation of scarce resources. This review identified and summarised the existing evidence of economic evaluations for the prevention of anxiety disorders in children and adolescents.

METHODS

A systematic search was conducted on the EBSCO, Scopus, Web of Science, ProQuest, Cochrane and PubMed databases. We included studies that focused on children and adolescents under 18 years of age, aimed to prevent anxiety disorders and presented an incremental analysis of costs and effectiveness. A registered checklist was used that assessed the quality of the included articles.

RESULTS

The search yielded 1697 articles. Five articles were included in this review. Three were RCT-based, and two were model-based studies. Out of five included interventions, one was a universal school-based intervention, two selective interventions and two indicated interventions. Universal school-based prevention of anxiety was not cost-effective compared with usual teaching. Selective parent training and indicative child- and parent-focused CBT prevention were likely cost-effective compared with usual care or doing nothing.

CONCLUSION

Parent education and cognitive behaviour therapy interventions can be cautiously interpreted as being a cost-effective way of preventing anxiety in children and adolescents. However, the evidence is weakly related to cost-effectiveness as there are only a few studies, with relatively small sample sizes and short follow-ups.

Mitigating the mental health consequences of mass shootings: An in-silico experiment

BACKGROUND

There is emerging evidence that mass shootings are associated with adverse mental health outcomes at the community level. Data from other mass-traumatic events examined the effectiveness of usual care (UC), (i.e., psychological first aid approaches without triage), and stepped care (SC) approaches, with triage, in reducing the burden of post-traumatic stress disorder (PTSD) in a community.

METHODS

We built an agent-based model of 118,000 people that was demographically comparable to the population of Parkland and Coral Springs, Florida, US. We parametrized the model with data from other traumatic events. Using simulations, we then estimated the community prevalence of PTSD one month following the Stoneman Douglas High School (Florida, US) shooting and reported the potential reach, effectiveness, and cost effectiveness of different what-if treatment scenarios (SC or UC) over a two-year period.

FINDINGS

One month following the mass shooting, PTSD prevalence in the community was 11.3% (95% CI: 11.1-11.5%). The reach of SC was 3461 (95% CI: 3573-3736) per 10,000 and the reach of UC was 2457 (95% CI: 2401-2510) per 10,000. SC was superior to UC in reducing PTSD prevalence, yielding, after two years, a risk difference of -0.044 (95% CI, -0.046 to -0.042) and a risk ratio of 0.452 (95% CI, 0.437-0.468). SC was also superior to UC in reducing the persistence of PTSD, yielding, after two years, a risk difference of -0.39 (95% CI, -0.401 to -0.379) and a risk ratio of 0.452 (95% CI, 0.439-0.465). The incremental cost-effectiveness of SC compared to UC was $2718.49 per DALYs saved, and $0.47 per PTSD-free day.

INTERPRETATION

This simulation demonstrated the potential benefits of different community-level approaches in mitigating the burden of PTSD following a mass shooting. These results warrant further research on community-based interventions to mitigate the mental health consequences of mass shootings.

FUNDING

None.

Economic evaluation of psychological treatments for common mental disorders in low- and middle-income countries: a systematic review

Common mental disorders (CMDs) constitute a major public health and economic burden on low- and middle-income countries (LMICs). Systematic reviews of economic evaluations of psychological treatments for CMDs are limited. This systematic review examines methods, reports findings and appraises the quality of economic evaluations of psychological treatments for CMDs in LMICs. We searched a range of bibliographic databases (including PubMed, EconLit, APA-PsycINFO and Cochrane library) and the African Journals Online (AJoL) and Google Scholar platforms. We used a pre-populated template to extract data and the Drummond & Jefferson checklist for quality appraisal. We present results as a narrative synthesis. The review included 26 studies, mostly from Asia (12) and Africa (9). The majority were cost-effectiveness analyses (12), some were cost-utility analyses (5), with one cost-benefit analysis or combinations of economic evaluations (8). Most interventions were considered either cost-effective or potentially cost-effective (22), with 3 interventions being not cost-effective. Limitations were noted regarding appropriateness of conclusions drawn on cost-effectiveness, the use of cost-effectiveness thresholds and application of 'societal' incremental cost-effectiveness ratios to reflect value for money (VfM) of treatments. Non-specialist health workers (NSHWs) delivered most of the treatments (16) for low-cost delivery at scale, and costs should reflect the true opportunity cost of NSHWs' time to support the development of a sustainable cadre of health care providers. There is a 4-fold increase in economic evaluations of CMD psychological treatments in the last decade over the previous one. Yet, findings from this review highlight the need for better application of economic evaluation methodology to support resource allocation towards the World Health Organization recommended first-line treatments of CMDs. We suggest impact inventories to capture societal economic gains and propose a VfM assessment framework to guide researchers in evaluating cost-effectiveness.

Multi-disciplinary Evaluation of Sexual Assault Referral Centres (SARCs) for better Health (MESARCH): protocol for a 1-year cohort study examining health, well-being and cost outcomes in adult survivors of sexual assault attending SARCs in England

INTRODUCTION

Sexual violence is commonplace and has serious adverse consequences for physical and mental health. Sexual Assault Referral Centres (SARCs) are viewed as a best practice response. Little is known about their effectiveness and cost-effectiveness. Long-term data on the health and well-being of those who have experienced rape and sexual assault are also lacking.

METHODS AND ANALYSIS

This is a mixed-methods protocol for a 1-year cohort study aiming to examine the health and well-being in survivors of sexual violence after attending a SARC in England. Quantitative measures are being taken at baseline, 6 and 12 months. Post-traumatic stress (PTS) is the primary outcome (target N=270 at 12-month follow-up). Secondary measures include anxiety, depression, substance use and sexual health and well-being. Using mixed-effects regression, our main analysis will examine whether variation in SARC service delivery and subsequent mental healthcare is associated with improvement in trauma symptoms after 12 months. An economic analysis will compare costs and outcomes associated with different organisational aspects of SARC service delivery and levels of satisfaction with care. A nested qualitative study will employ narrative analysis of transcribed interviews with 30 cohort participants and 20 survivors who have not experienced SARC services.

ETHICS AND DISSEMINATION

The research is supported by an independent study steering committee, data monitoring and ethics committee and patient and public involvement (PPI) group. A central guiding principle of the research is that being involved should feel diametrically opposed to being a victim of sexual violence, and be experienced as empowering and supportive. Our PPI representatives are instrumental in this, and our wider stakeholders encourage us to consider the health and well-being of all involved. We will disseminate widely through peer-reviewed articles and non-academic channels to maximise the impact of findings on commissioning of services and support for survivors.

TRIAL REGISTRATION NUMBER

ISRCTN30846825.

Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Nationwide Routine Care: Effectiveness Study

Background

Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficacious for generalized anxiety disorder (GAD), but few studies are yet to report its effectiveness in routine care.

Objective

In this study, we aim to examine whether a new 12-session iCBT program for GAD is effective in nationwide routine care.

Methods

We administered a specialized, clinic-delivered, therapist-supported iCBT for GAD in 1099 physician-referred patients. The program was free of charge for patients, and the completion time was not predetermined. We measured symptoms with web-based questionnaires. The primary measure of anxiety was the GAD 7-item scale (GAD-7); secondary measures were, for pathological worry, the Penn State Worry Questionnaire and, for anxiety and impairment, the Overall Anxiety Severity and Impairment Scale.

Results

Patients completed a mean 7.8 (SD 4.2; 65.1%) of 12 sessions, and 44.1% (485/1099) of patients completed all sessions. The effect size in the whole sample for GAD-7 was large (Cohen d=0.97, 95% CI 0.88-1.06). For completers, effect sizes were very large (Cohen d=1.34, 95% CI 1.25-1.53 for GAD-7; Cohen d=1.14, 95% CI 1.00-1.27 for Penn State Worry Questionnaire; and Cohen d=1.23, 95% CI 1.09-1.37 for Overall Anxiety Severity and Impairment Scale). Noncompleters also benefited from the treatment. Greater symptomatic GAD-7–measured relief was associated with more completed sessions, older age, and being referred from private or occupational care. Of the 894 patients with a baseline GAD-7 score ≥10, approximately 421 (47.1%) achieved reliable recovery.

Conclusions

This nationwide, free-of-charge, therapist-supported HUS Helsinki University Hospital–iCBT for GAD was effective in routine care, but further research must establish effectiveness against other treatments and optimize the design of iCBT for GAD for different patient groups and individual patients.

Strategies to improve access to cognitive behavioral therapies for anxiety disorders: A scoping review

Background

Strategies to improve access to evidence-based psychological treatments (EBPTs) include but are not limited to implementation strategies. No currently available framework accounts for the full scope of strategies available to allow stakeholders to improve access to EBPTs. Anxiety disorders are common and impactful mental conditions for which EBPTs, especially cognitive-behavioral therapies (CBT), are well-established yet often hard to access.

Objective

Describe and classify the various strategies reported to improve access to CBT for anxiety disorders.

Methods

Scoping review with a keyword search of several databases + additional grey literature documents reporting on strategies to improve access to CBT for anxiety disorders. A thematic and inductive analysis of data based on grounded theory principles was conducted using NVivo.

Results

We propose to classify strategies to improve access to CBT for anxiety disorders as either "Contributing to the evidence base," "Identifying CBT delivery modalities to adopt in practice," "Building capacity for CBT delivery," "Attuning the process of access to local needs," "Engaging potential service users," or "Improving programs and policies." Each of these strategies is defined, and critical information for their operationalization is provided, including the actors that could be involved in their implementation.

Implications

This scoping review highlights gaps in implementation research regarding improving access to EBPTs that should be accounted for in future studies.

Reducing problematic alcohol use in employees: economic evaluation of guided and unguided web-based interventions alongside a three-arm randomized controlled trial

AIMS

To perform an economic evaluation of guided and unguided internet-based interventions to reduce problematic alcohol consumption in employees compared with a waiting-list control condition (WLC) with unrestricted access to treatment-as-usual.

DESIGN

A cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a societal and a cost-benefit analysis from the employer's perspective with a 6-month time horizon.

SETTING

Open recruitment in the German working population.

PARTICIPANTS

Employees (178 males, 256 females, mean age 47 years) consuming at least 14 (women) or 21 (men) standard units of alcohol (SUAs) per week and scoring ≥ 8 (men) or 6 (women) on the Alcohol Use Disorders Identification Test.

MEASUREMENTS

On-line questionnaires administered to assess SUAs and assess quality of life (AQoL-8D) and resource use. Outcome measure was responder (≤ 14/≤ 21 SUAs) for the CEA and quality-adjusted life years (QALYs) for the CUA. Net benefit regression was used to estimate cost-effectiveness for each study arm. Bootstrapping and sensitivity analyses were performed to account for uncertainty.

INTERVENTIONS

Five weekly modules including personalized normative feedback, motivational interviewing, goal setting, problem-solving and emotion regulation, provided with adherence-focused guidance [n = 142; responders: n = 73 (51.4%); QALYs = 0.364, standard error (SE) = 0.006] or without guidance [n = 146; n = 66 (45.2%); 0.359, 0.007]. Controls were on a waiting-list [n = 144; n = 38 (26.4%); 0.342, 0.007].

FINDINGS

From a societal perspective, the guided intervention had a probability of 55% (54%) of being the most efficient strategy at a willingness-to-pay (WTP) of €0 per responder (QALY) gained, compared with the unguided intervention and the control condition. At a WTP of €20 000 per QALY gained, the probability was 78%. From an employer's perspective, the guided intervention had a higher probability of a positive return on investment (81%) compared with the unguided intervention (58%).

CONCLUSION

A guided internet-based intervention to reduce problematic alcohol consumption in employees appears to be both cost-beneficial and cost-effective.

Intervention cost-effectiveness for pediatric anxiety and OCD: A systematic review and integrated database model

BACKGROUND

While multiple treatments for pediatric anxiety and obsessive compulsive disorder (OCD) are efficacious, little is known about their cost-effectiveness. In response, we sought to provide relevant information through systematic review and cost-effectiveness simulation.

METHODS

We evaluated the cost-effectiveness of treatment for pediatric anxiety and OCD in two ways. First, we conducted a systematic review following PRISMA guidelines. Second, we evaluated cost-effectiveness for antidepressant medication, cognitive behavioral therapy, and their combination via a simulation that integrated information from the Truven MarketScan database and the NIMH National Database for Clinical Trials Related to Mental Illness.

RESULTS

Both systematic review and simulation found antidepressant medication and cognitive behavioral therapy to be cost-effective for pediatric anxiety and OCD. Antidepressant medication was the least costly approach, and cognitive behavioral therapy provided additional cost-effectiveness, especially for OCD.

LIMITATIONS

During systematic review, relatively few articles provided information about both costs and effectiveness. While there was a notable margin of error to support multiple interventions as cost-effective, limited prior research decreased precision of point estimates and comparisons between interventions.

CONCLUSIONS

Both antidepressant medication and cognitive behavioral therapy were found to be cost-effective for pediatric anxiety and OCD. Results supported investment from third party payers, who serve as critical gatekeepers that can increase treatment dissemination. However, more precise information would better inform the exact amount of investment needed, especially with regard to selection decisions between active interventions. Cost-effectiveness research would benefit from systematic collection of data on treatment costs and quality of life in future clinical trials.

Youths' and Parents' Experiences and Perceived Effects of Internet-Based Cognitive Behavioral Therapy for Anxiety Disorders in Primary Care: Mixed Methods Study

BACKGROUND

Anxiety is common among youths in primary care. Face-to-face treatment has been the first choice for clinicians, but during the COVID-19 pandemic, digital psychological interventions have substantially increased. Few studies have examined young people's interest in internet treatment or the attitudes they and their parents have toward it.

OBJECTIVE

This study aims to investigate adolescents' and parents' attitudes toward and experiences of internet-based cognitive behavioral anxiety treatment in primary care and its presumptive effects.

METHODS

The study used mixed methods, analyzing qualitative data thematically and quantitative data with nonparametric analysis. Participants were 14 adolescents and 14 parents recruited in adolescent primary health care clinics. The adolescents and their parents filled out mental health questionnaires before and after treatment, and were interviewed during ongoing treatment.

RESULTS

The quantitative data indicated that the internet-delivered cognitive behavioral therapy program used in this study was successful in reducing symptoms (χ²₂=8.333; P=.02) and that adolescents' motivation is essential to the treatment outcome (r=0.58; P=.03). The qualitative results show that youths highly value their independence and freedom to organize treatment work on their own terms. The parents expressed uncertainty about their role and how to support their child in treatment. It was important for parents to respect the youths' need for autonomy while also engaging with them in the treatment work.

CONCLUSIONS

Internet treatment in primary care is accepted by both youths and their parents, who need clarification about the difference between their role and the therapist's role. Patient motivation should be considered before treatment, and therapists need to continue to develop the virtual alliance. Finally, primary care should be clearer in informing adolescents and their parents about the possibility of internet treatment.

Broad spectrum micronutrient formulas for the treatment of symptoms of depression, stress, and/or anxiety: a systematic review

Introduction: Vitamin and mineral nutritional supplements are becoming increasingly popular as alternative treatments for anxiety and depression, as issues such as side effects from medication, failure to respond to psychotherapy and workforce limitations pose barriers for successful treatment.Areas covered: This review covered double-blind, randomized controlled trials (DBRCTs) testing formulas including at least four vitamins and/or minerals used for the treatment of symptoms of anxiety, stress, or depression in adults not currently taking medication for psychiatric difficulties.Expert opinion: The majority of the 23 trials reviewed were conducted on people without psychological difficulties, limiting the generalizability of the results in people with diagnosed mood and anxiety difficulties. Sixteen studies demonstrated positive effects for symptoms of anxiety, depression, or stress. Micronutrient supplementation in healthy nonclinical adults has limited benefits for mood and anxiety symptoms, although may convey some subtle general improvements. The evidence for adults with physical or mental ill health is more positive although limited by small samples and variability in nutrients studied. Broad-spectrum nutrient products may be more effective than a selected few. While an effect of micronutrients cannot be dismissed, the variability of the studies makes it extremely challenging to identify specific treatment benefits.

Economic Evaluations of Internet-Based Psychological Interventions for Anxiety Disorders and Depression: A Systematic Review

BACKGROUND

Internet-based interventions show clinical effectiveness for treating anxiety disorders and depression and could make mental healthcare more affordable.

METHODS

We searched databases including PubMed; EMBASE; Cochrane Central; PsychINFO; CINAHL; EconLit; and Web of Science from January 1, 2000 to August 21, 2020. Inclusion criteria were: 1) pertained to the treatment or prevention of anxiety disorders or depression; 2) evaluated the use of an internet-delivered psychological intervention; 3) recruited participants; and 4) reported costs or cost-effectiveness.

RESULTS

Of the 6,069 articles identified, 33 targeted anxiety (N=13) and depression (n=20) and met final inclusion criteria. All studies were from high-income countries. The control conditions and cost components included were heterogeneous. Only eight studies reported costs of developing the intervention. Of 27 studies that made a conclusion about cost-effectiveness, 81% of interventions were cost-effective. The quality of studies included was high based on a quality assessment checklist of economic evaluations, although many studies did not include definitions of cost components or differentiate between patient-side and system-level costs.

LIMITATIONS

Studies varied in methodology, making conclusions about cost-effectiveness difficult. The generalizability of these results is unclear as studies were clustered in a small number of high-income countries and costs vary over time and between regions.

CONCLUSIONS

Internet-delivered interventions appeared to be cost-effective although control conditions and cost component reporting were variable. We propose a checklist of cost components for future cost analyses to better compare intervention costs. More research is needed to describe development costs, cost-effectiveness in low-resource settings, and cost-effectiveness of newer technologies.

Cost-effectiveness of Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care

IMPORTANCE

Youth anxiety and depression are common and undertreated. Pediatric transdiagnostic interventions for anxiety and/or depression may be associated with improved access to treatment among youths.

OBJECTIVE

To evaluate the cost-effectiveness of a pediatric transdiagnostic brief behavioral therapy (BBT) program for anxiety and/or depression compared with assisted referral to community outpatient mental health care (ARC).

DESIGN, SETTING, AND PARTICIPANTS

In this economic evaluation, an incremental cost-effectiveness analysis was performed from the societal perspective using data from a randomized clinical trial of youths with full or probable diagnoses of anxiety or depression who were recruited from pediatric clinics in San Diego, California, and Pittsburgh, Pennsylvania. The trial was conducted from October 6, 2010, through December 5, 2014, and this analysis was performed from January 1, 2019, through October 20, 2020.

INTERVENTIONS

In the randomized clinical trial, youths were randomized to BBT (n = 95) or ARC (n = 90). The BBT program consisted of 8 to 12 weekly 45-minute sessions of behavioral therapy delivered in pediatric clinics by master's-level therapists. Families randomized to ARC received personalized referrals to mental health care and telephone calls to support access to care.

MAIN OUTCOMES AND MEASURES

Anxiety-free days, depression-free days, quality-adjusted life-years (QALYs), and costs based on incremental cost-effectiveness ratios from intake through 32-week follow-up. A cost-effectiveness acceptability curve for QALYs was used to assess the probability that BBT was cost-effective compared with ARC over a range of amounts that a decision-maker might be willing to pay for an additional outcome.

RESULTS

Enrolled patients included 185 youths (mean [SD] age, 11.3 [2.6] years; 107 [57.8%] female; 144 [77.8%] White; and 38 [20.7%] Hispanic). Youths who received BBT experienced significantly more anxiety-free days (difference, 28.63 days; 95% CI, 5.86-50.71 days; P = .01) and QALYs (difference, 0.026; 95% CI, 0.009-0.046; P = .007) compared with youths who received ARC. Youths who received BBT experienced more depression-free days than did youths who received ARC (difference, 10.52 days; 95% CI, -4.50 to 25.76 days; P = .18), but the difference was not statistically significant. The mean incremental cost-effectiveness ratio was -$41 414 per QALY (95% CI, -$220 601 to $11 468). The cost-effectiveness acceptability curve analysis indicated that, at a recommended willingness-to-pay threshold of $50 000 per QALY, the probability that BBT would be cost-effective compared with ARC at 32 weeks was 95.6%.

CONCLUSIONS AND RELEVANCE

In this economic evaluation, BBT in primary care was significantly associated with better outcomes and a greater probability of cost-effectiveness at 32 weeks compared with ARC. The findings suggest that transdiagnostic BBT may be associated with improved youth anxiety and functioning at a reasonable cost.

Anxiety and Depression: A Key to Understanding the Complete Expression of Personality Disorders

ABSTRACT

Anxiety and depressive disorders affect one fourth of the population. Personality disorders often present comorbid with anxiety and depressive disorders during the lifetime course of the illness. To fully explore the interplay between personality disorders and anxiety or depression, 179 patients, consecutively admitted to the Anxiety and Depression Outpatient Department, were clinically evaluated and tested with the Mini-International Neuropsychiatric Interview and the Iowa Personality Disorder Screening. Twenty-six percent of the total sample was affected only by personality disorders (PDs), and 21% had a comorbidity between a personality, anxiety, and/or depressive disorder (Comorbidity). Compared with PDs, Comorbidity used more antipsychotics and benzodiazepines (4.3% vs. 9.6%, χ2 = 0.267; 43.4 vs. 72.6, p = 0.004), showing a worse clinical picture, and expressed more personality traits even without statistical significance (6.863 ± 2.328 vs. 7.609 ± 1.674, p = 0.105). The different impact of personality disorders compared with anxiety and/or depression has to be further analyzed in terms of economic load and resource allocation.

Economic evaluations of psychological treatments for common mental disorders in low- and middle-income countries: protocol for a systematic review

BACKGROUND

Common mental disorders (CMDs) are highly prevalent conditions that constitute a major public health and economic burden on society in low- and middle-income countries (LMICs). Despite the increased demand for economic evidence to support resource allocation for scaled-up implementation of mental health services in these contexts, economic evaluations of psychological treatments for CMDs remain scarce.

OBJECTIVE

The proposed systematic review aims to synthesize findings on methods and outcomes of economic evaluations of psychological treatments for CMDs in LMICs and appraise quality.

METHODS

We will identify, select, and extract data from published economic evaluations of psychological interventions for CMDs conducted in LMICs. We will search bibliographic databases (PubMed, EMBASE, CINAHL, Web of Science, EconLit, PsycINFO, Africa-Wide Information, Cochrane library, Centre for Reviews and Dissemination (CRD), Cost Effectiveness Analysis (CEA) Registry), and the African Journals Online (AJOL) and Google Scholar platforms. Only full economic evaluations (Cost-Effectiveness Analysis (CEA), Cost-Utility Analysis (CUA), Cost-Consequence Analysis (CCA), or Cost-Benefit Analysis (CBA)) of psychological treatments for CMDs (defined as depressive, anxiety, and substance use disorders) conducted in LMICs will be included. There will be no restrictions based on date of publication, perspective, follow-up duration or sample size. Data extraction will be guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

The results presented will be examined using a narrative synthesis approach. The quality of included studies will be assessed using the Drummond & Jefferson checklist.

CONCLUSION

The fledgling evidence base in this area provides an opportunity to promote improved economic evaluation methods in line with repeated calls for economic evidence alongside effectiveness evidence in these settings. A rigorously developed economic evaluation evidence base will support resource allocation decisions for scaled up implementation of psychological interventions in LMIC settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020185277.

Transitioning from face-to-face treatment to iCBT for youths in primary care - therapists' attitudes and experiences

BACKGROUND

To address the increasing mental health problems among young people, health care needs to broaden the spectrum of interventions and increase access to care. One particularly promising first-line intervention is cognitive behavioral therapy (CBT) delivered via the Internet (iCBT). The outbreak of the Coronavirus disease -2019 (COVID -19) has made the need for solid digital mental health care systems clear. This is the first published study exploring the transition among therapists of working with face-to-face treatment to using iCBT for youths suffering from anxiety treated in primary care.

METHODS

Fourteen primary care therapists were included in the study. Semi-structured interviews (n = 26) were conducted on two occasions: before starting to use iCBT for youths, and at a subsequent follow-up after gaining treatment experience. Data was summarized into thematic categories.

RESULTS

The overarching themes that were identified were: Attitudes to iCBT before and after implementation; Experiences of treatment delivery; Characteristics of "the right patient;" and The role of the digital therapist.

CONCLUSION

The participants generally had positive attitudes to iCBT for youths and saw it as a valuable alternative to face-to-face treatments. However, they identified challenges related to patient selection, and to motivating patients and maintaining a therapeutic relationship through mainly written communication. The participants appreciated the increase in variety that iCBT brought to their schedules, and also experienced iCBT as a relief from common challenges of therapeutic work, such as emotional stress and high cognitive demands. The participating therapists' positive experiences support the introduction of iCBT for youths in routine primary care.

Economic evaluations of non-pharmacological interventions and cost-of-illness studies in bipolar disorder: A systematic review

Background Bipolar disorder (BD) is associated with substantial societal burden. Therefore, economic studies in BD are becoming increasingly important. The goal of the current study is three-fold: (1) summarize the evidence regarding economic evaluations (EEs) of non-pharmacological interventions for BD, (2) summarize cost-of-illness studies (COIs) for BD published 2012 or later and (3) assess the quality of the identified studies. Methods A systematic search was conducted in MedLine, EMBASE and PsycINFO. For both EEs and COIs, quality assessments were conducted and general and methodological characteristics of the studies were extracted. Outcomes included incremental-cost-effectiveness ratios for EEs and direct and indirect costs for COIs. Results Eight EEs and ten COIs were identified. The included studies revealed high heterogeneity in general and methodological characteristics and study quality. All interventions resulted in improved clinical outcomes. Five studies additionally concluded decreased total costs. For COIs, we found a wide range of direct ($881-$27,617) and indirect cost estimates per capita per year ($1,568-$116,062). Limitations High heterogeneity in terms of interventions, study design and outcomes made it difficult to compare results across studies. Conclusions Interventions improved clinical outcomes in all studies and led to cost-savings in five studies. Findings suggest that non-pharmacological intervention for BD might be cost-effective. Studies on the costs of BD revealed that BD has a substantial economic burden. However, we also found that the number of EEs was relatively low and methodology was heterogenous and therefore encourage future research to widen the body of knowledge in this research field and use standardized methodology.

What are the Key Characteristics of a 'Good' Psychotherapy? Calling for Ethical Patient Involvement

OBJECTIVE

The evidence-based practice movement clearly defines the relevant components of a good treatment. In the present article, we elaborate on how the active involvement of patients within psychotherapy can and should be increased in order to respect ethical considerations. Our arguments complement the requirements of evidence-based practice, and are independent of the actual psychotherapeutic treatment approach being used.

METHOD

Theoretical and ethical analysis.

RESULTS

In order to respect patient autonomy, psychotherapy needs to be transparent and honest when it comes to disclosing the relevant factors for promoting therapeutic change. It has been argued that ethical informed consent needs to include empirically supported patient information. In this paper we go one step further: we outline that fully respecting ethical considerations in psychotherapeutic treatment necessarily calls for acknowledging and strengthening the active role of patients in the course of psychotherapy. Accordingly, patients need not only to be informed openly and transparently about the planned treatment, the treatment rationale, and the expected prognosis of improvement in the course of psychotherapy, but they also need to be actively involved in the decision-making process and during the entire process of psychotherapeutic treatment.

CONCLUSIONS

Our arguments support the tendency that can be observed in health care in recent years towards more active patient involvement across different health-care domains, but also in clinical research. This article offers an ethical perspective on the question what defines a 'good psychotherapy', which, hopefully, will help to leave behind some of the ongoing psychotherapy debates and move the field forward.

Targets and outcomes of psychotherapies for mental disorders: an overview

It is not yet clear what mental disorders are and what are the causal pathways that lead to them. That makes it difficult to decide what the targets and outcomes of psychotherapies should be. In this paper, the main types of targets and outcomes of psychotherapies are described, and a brief overview is provided of some of the main results of research on these types. These include symptom reduction, personal targets and outcomes from the patient's perspective, improvement of quality of life, intermediate outcomes depending on the theoretical framework of the therapist, negative outcomes to be avoided, and economic outcomes. In line with the dominance of the DSM and ICD systems for diagnoses, most research has been focused on symptom reduction. This considerable body of research, with hundreds of randomized trials, has shown that for most mental disorders effective psychotherapies are available. There is also research showing that psychotherapies can result in improvement of quality of life in most mental disorders. However, relatively little research is available on patient-defined outcomes, intermediate outcomes, negative outcomes and economic outcomes. Patients, relatives, therapists, employers, health care providers and society at large each have their own perspectives on targets and outcomes of psychotherapies. The perspective of patients should have more priority in research, and a standardization of outcome measures across trials is much needed.

[Child psychiatry interventions in patients with 22q11 deletion syndrome: From treatment to prevention]

22q11.2DS is one of the more frequent genetic syndromes associated to psychiatric symptoms. It has been associated to an increased risk to develop schizophrenia in adolescence or early adulthood. However, psychiatric symptoms appear early on, and should be recognized as soon as possible by child psychiatrists in order to improve the present well-being of children and their family, and to prevent further risks of developing severe and chronic psychiatric diseases later on. In this paper, we present a review of the recent literature concerning the 22q11.2DS syndrome focused on the risk factors that may be associated to an increased risk of psychotic transition. We advocate for the development of systematic specialized child psychiatry consultations for these patients, included in networks with geneticists, adult psychiatrists, and family associations, in order to improve their psychiatric prognosis and to support the development of translational research.

Value of information analysis of an early intervention for subthreshold panic disorder: Healthcare versus societal perspective

Background

Panic disorder is associated with high productivity costs. These costs, which should be included in cost-effectiveness analyses (CEA) from a societal perspective, have a considerable impact on cost-effectiveness estimates. However, they are often omitted in published CEAs. It is therefore uncertain whether choosing a societal perspective changes priority setting in future research as compared to a healthcare perspective.

Objectives

To identify research priorities regarding the cost-effectiveness of an early intervention for subthreshold panic disorder using value of information (VOI) analysis and to investigate to what extent priority setting depends on the perspective.

Methods

We calculated the cost-effectiveness of an early intervention for panic disorder from a healthcare perspective and a societal perspective. We performed a VOI analysis, which estimates the expected value of eliminating the uncertainty surrounding cost-effectiveness estimates, for both perspectives.

Results

From a healthcare perspective the early intervention was more effective at higher costs compared to usual care (€17,144 per QALY), whereas it was cost-saving from a societal perspective. Additional research to eliminate parameter uncertainty was valued at €129.7 million from a healthcare perspective and €29.5 million from a societal perspective. Additional research on the early intervention utility gain was most valuable from a healthcare perspective, whereas from a societal perspective additional research would generate little added value.

Conclusions

Priority setting for future research differed substantially according to the perspective. Our study underlines that the health-economic perspective of CEAs on interventions for panic disorder must be chosen carefully in order to avoid inappropriate choices in research priorities.

Economic Evaluations of Falls Prevention Programs for Older Adults: A Systematic Review

OBJECTIVES

To provide a comprehensive overview of economic evaluations of falls prevention programs and to evaluate the methodology and quality of these studies.

DESIGN

Systematic review of economic evaluations on falls prevention programs.

SETTING

Studies (N=31) of community-dwelling older adults (n=25), of older adults living in residential care facilities (n=3), and of both populations (n=3) published before May 2017.

PARTICIPANTS

Adults aged 60 and older.

MEASUREMENTS

Information on study characteristics and health economics was collected. Study quality was appraised using the 20-item Consensus on Health Economic Criteria.

RESULTS

Economic evaluations of falls prevention through exercise (n = 9), home assessment (n = 6), medication adjustment (n = 4), multifactorial programs (n = 11), and various other programs (n = 13) were identified. Approximately two-thirds of all reported incremental cost-effectiveness ratios (ICERs) with quality-adjusted life-years (QALYs) as outcome were below the willingness-to-pay threshold of $50,000 per QALY. All studies on home assessment and medication adjustment programs reported favorable ICERs, whereas the results of studies on exercise and multifactorial programs were inconsistent. The overall methodological quality of the studies was good, although there was variation between studies.

CONCLUSION

The majority of the reported ICERs indicated that falls prevention programs were cost-effective, but methodological differences between studies hampered direct comparison of the cost-effectiveness of program types. The results imply that investing in falls prevention programs for adults aged 60 and older is cost-effective. Home assessment programs (ICERs < $40,000/QALY) were the most cost-effective type of program for community-dwelling older adults, and medication adjustment programs (ICERs < $13,000/QALY) were the most cost-effective type of program for older adults living in a residential care facility. J Am Geriatr Soc 66:2197-2204, 2018.

Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review

BACKGROUND

In primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies.

METHODS

We searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality.

RESULTS

A total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes.

CONCLUSION

This review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions.

REGISTRATION

Study methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.

Study Protocol for a Randomized Double Blind, Placebo Controlled Trial Exploring the Effectiveness of a Micronutrient Formula in Improving Symptoms of Anxiety and Depression

Background: Anxiety and depression are conferring an increasing burden on society. Although treatments exist for both conditions, side effects, and difficulties accessing treatment prevent many people from receiving adequate assistance. Nutritional approaches have demonstrated some success in treating anxiety and depression. We plan to investigate whether a micronutrient formula, Daily Essential Nutrients, improves symptoms of anxiety and depression compared to a placebo in a community recruited sample. Methods: This will be a randomized, double blind placebo controlled study (RCT). Two hundred adults will be assigned to either a placebo or micronutrient group (placebo or Daily Essential Nutrients (DEN)) in a 1:1 ratio. Baseline data will be collected for 2 weeks, followed by 10 weeks of placebo or micronutrient intervention. Psychometrics will be used to measure progress and participant safety will be monitored weekly. Results: The primary outcome measures will be total scores on three measures of symptom severity at 10 weeks. Linear mixed modelling will be used to measure between group differences and effect sizes will be calculated using pooled mean scores and standard deviations over the course of the trial. Conclusions: If effective, micronutrients could provide an alternative treatment, with fewer barriers and adverse events than currently available treatments.

Cost-Effectiveness of Facilitated Access to a Self-Management Website, Compared to Usual Care, for Patients With Type 2 Diabetes (HeLP-Diabetes): Randomized Controlled Trial

Background

Type 2 diabetes mellitus is one of the most common long-term conditions, and costs health services approximately 10% of their total budget. Active self-management by patients improves outcomes and reduces health service costs. While the existing evidence suggested that uptake of self-management education was low, the development of internet-based technology might improve the situation.

Objective

To establish the cost-effectiveness of a Web-based self-management program for people with type 2 diabetes (HeLP-Diabetes) compared to usual care.

Methods

An incremental cost-effectiveness analysis was conducted, from a National Health Service and personal and social services perspective, based on data collected from a multi-center, two-arm individually randomized controlled trial over 12 months. Adults aged 18 or over with a diagnosis of type 2 diabetes and registered with the 21 participating general practices (primary care) in England, UK, were approached. People who were unable to provide informed consent or to use the intervention, terminally ill, or currently participating in a trial of an alternative self-management intervention, were excluded. The participants were then randomized to either usual care plus HeLP-Diabetes, an interactive, theoretically-informed Web-based self-management program, or to usual care plus access to a comparator website containing basic information only. The participants’ intervention costs and wider health care resource use were collected as well as two health-related quality of life measures: the Problem Areas in Diabetes (PAID) Scale and EQ-5D-3L. EQ-5D-3L was then used to calculate quality-adjusted life years (QALYs). The primary analysis was based on intention-to-treat, using multiple imputation to handle the missing data.

Results

In total, 374 participants were randomized, with 185 in the intervention group and 189 in the control group. The primary analysis showed incremental cost-effectiveness ratios of £58 (95% CI –411 to 587) per unit improvement on PAID scale and £5550 (95% CI –21,077 to 52,356) per QALY gained by HeLP-Diabetes, compared to the control. The complete case analysis showed less cost-effectiveness and higher uncertainty with incremental cost-effectiveness ratios of £116 (95% CI –1299 to 1690) per unit improvement on PAID scale and £18,500 (95% CI –203,949 to 190,267) per QALY. The cost-effectiveness acceptability curve showed an 87% probability of cost-effectiveness at £20,000 per QALY willingness-to-pay threshold. The one-way sensitivity analyses estimated 363 users would be needed to use the intervention for it to become less costly than usual care.

Conclusions

Facilitated access to HeLP-Diabetes is cost-effective, compared to usual care, under the recommended threshold of £20,000 to £30,000 per QALY by National Institute of Health and Care Excellence.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 02123133; http://www.controlled-trials.com/ISRCTN02123133 (Archived by WebCite at http://www.webcitation.org/6zqjhmn00)

Early intervention for subthreshold panic disorder in the Netherlands: A model-based economic evaluation from a societal perspective

Background

Panic disorder (PD) is associated with impaired functioning and reduced quality of life. In the Netherlands, almost 2% of the population experiences clinically relevant panic symptoms without meeting the diagnostic criteria for PD, which is referred to as subthreshold PD (STHPD). Evidence suggests that subthreshold mental disorders may have a similar impact on quality of life and functioning in comparison with full-blown mental disorders, which draws attention to the need for interventions for STHPD. These interventions are currently not systematically provided in clinical practice. This study aims to investigate the population cost-effectiveness of adding a CBT-based early intervention for adults with STHPD to the existing health care for people with PD in the Netherlands.

Methods

A health-economic Markov model was constructed in order to compare quality adjusted life-years (QALYs) and societal costs of adding an early intervention to usual care for PD. The model compares usual care with an alternative program in which usual care is supplemented with a CBT-based early intervention. Input parameters for the model were derived from national sources and published literature where possible, and based on expert opinion otherwise. Probabilistic and deterministic sensitivity analyses were conducted to evaluate the uncertainty of the model input parameters.

Results

On average, the added CBT-based early intervention was dominant in comparison with usual care, meaning that the early intervention yielded more QALYs at lower costs. At a willingness-to-pay threshold of €20,000 per QALY, the cost-effectiveness probability of the added early intervention was 98%. Sensitivity analyses showed that the results were robust.

Conclusions

This study showed that offering an early intervention in addition to usual care for PD is potentially cost-effective, but it should be further investigated to what extent trial results can be extrapolated to the level of the population before such interventions are implemented on a large scale.

Mobile and traditional cognitive behavioral therapy programs for generalized anxiety disorder: A cost-effectiveness analysis

Background

Generalized anxiety disorder (GAD) is a debilitating mental health illness that affects approximately 3.1% of U.S. adults and can be treated with cognitive behavioral therapy (CBT). With the emergence of digital health technologies, mobile CBT may be a cost-effective way to deliver care. We developed an analysis framework to quantify the cost-effectiveness of internet-based CBT for individuals with GAD. As a case study, we examined the potential value of a new mobile-delivered CBT program for GAD.

Methods

We developed a Markov model of GAD health states combined with a detailed economic analysis for a cohort of adults with GAD in the U.S. In our case study, we used pilot program efficacy data to evaluate a mobile CBT program as either prevention or treatment only and compared the strategies to traditional CBT and no CBT. Traditional CBT efficacy was estimated from clinical trial results. We calculated discounted incremental costs and quality-adjusted life-years (QALYs) over the cohort lifetime.

Case study results

In the base case, for a cohort of 100,000 persons with GAD, we found that mobile CBT is cost-saving. It leads to a gain of 34,108 QALYs and 81,492 QALYs and a cost reduction of $2.23 billion and $4.54 billion when compared to traditional CBT and no CBT respectively. Results were insensitive to most model inputs and mobile CBT remained cost-saving in almost all scenarios.

Limitations

The case study was conducted for illustrative purposes and used mobile CBT efficacy data from a small pilot program; the analysis should be re-conducted once robust efficacy data is available. The model was limited in its ability to measure the effectiveness of CBT in combination with pharmacotherapy.

Conclusions

Mobile CBT may lead to improved health outcomes at lower costs than traditional CBT or no intervention and may be effective as either prevention or treatment.

Comparison of Simulated Treatment and Cost-effectiveness of a Stepped Care Case-Finding Intervention vs Usual Care for Posttraumatic Stress Disorder After a Natural Disaster

IMPORTANCE

Psychiatric interventions offered after natural disasters commonly address subsyndromal symptom presentations, but often remain insufficient to reduce the burden of chronic posttraumatic stress disorder (PTSD).

OBJECTIVE

To simulate a comparison of a stepped care case-finding intervention (stepped care [SC]) vs a moderate-strength single-level intervention (usual care [UC]) on treatment effectiveness and incremental cost-effectiveness in the 2 years after a natural disaster.

DESIGN, SETTING, AND PARTICIPANTS

This study, which simulated treatment scenarios that start 4 weeks after landfall of Hurricane Sandy on October 29, 2012, and ending 2 years later, created a model of 2 642 713 simulated agents living in the areas of New York City affected by Hurricane Sandy.

INTERVENTIONS

Under SC, cases were referred to cognitive behavioral therapy, an evidence-based therapy that aims to improve symptoms through problem solving and by changing thoughts and behaviors; noncases were referred to Skills for Psychological Recovery, an evidence-informed therapy that aims to reduce distress and improve coping and functioning. Under UC, all patients were referred only to Skills for Psychological Recovery.

MAIN OUTCOMES AND MEASURES

The reach of SC compared with UC for 2 years, the 2-year reduction in prevalence of PTSD among the full population, the 2-year reduction in the proportion of PTSD cases among initial cases, and 10-year incremental cost-effectiveness.

RESULTS

This population of 2 642 713 simulated agents was initialized with a PTSD prevalence of 4.38% (115 751 cases) and distributions of sex (52.6% female and 47.4% male) and age (33.9% aged 18-34 years, 49.0% aged 35-64 years, and 17.1% aged ≥65 years) that were comparable with population estimates in the areas of New York City affected by Hurricane Sandy. Stepped care was associated with greater reach and was superior to UC in reducing the prevalence of PTSD in the full population: absolute benefit was clear at 6 months (risk difference [RD], -0.004; 95% CI, -0.004 to -0.004), improving through 1.25 years (RD, -0.015; 95% CI, -0.015 to -0.014). Relative benefits of SC were clear at 6 months (risk ratio, 0.905; 95% CI, 0.898-0.913), with continued gains through 1.75 years (risk ratio, 0.615; 95% CI, 0.609-0.662). The absolute benefit of SC among cases was much stronger, emerging at 3 months (RD, -0.006; 95% CI, -0.007 to -0.005) and increasing through 1.5 years (RD, -0.338; 95% CI, -0.342 to -0.335). Relative benefits of SC among cases were equivalent to those observed in the full population. The incremental cost-effectiveness of SC compared with UC was $3428.71 to $6857.68 per disability-adjusted life year avoided, and $0.80 to $1.61 per PTSD-free day.

CONCLUSIONS AND RELEVANCE

The results of this simulation study suggest that SC for individuals with PTSD in the aftermath of a natural disaster is associated with greater reach than UC, more effectiveness than UC, and is well within the range of acceptability for cost-effectiveness. Results should be considered in light of limitations inherent to agent-based models.