[Incapacity to work due to mental disorders-economic, individual, and treatment-specific aspects]

The changes in the modern work environment are accompanied by specific stressors that can have a negative impact on employees' mental health. In line with this, the proportion of sick-leave days due to mental disorders has recently risen to 17.7% compared to 10.9% in 2007, which in 2021 was associated with costs of 42.9 billion euros due to losses of gross value and productivity.Based on current health economic studies, this review provides an overview of the economic impact of incapacity to work and early retirement due to various mental disorders in Germany. In absolute figures, expenditure on incapacity to work is particularly high for common mental illnesses such as affective and anxiety disorders. Rarer mental disorders such as post-traumatic stress disorder and eating disorders cause high costs in relation to their low prevalence, particularly due to sickness benefit payments.In addition to these economic implications, the consequences of incapacity to work, early retirement, and unemployment are examined at an individual level and explanatory approaches for the specific psychosocial stresses are presented. The latter highlights the need for scientifically substantiated treatment methods. Certified treatments have proven to be efficient in reducing the number of sick-leave days, particularly for common mental disorders. This applies even more to workplace-related interventions, which appear to be superior to conventional methods in this respect. Workplace-based therapies incorporate work-related models and focus on the planning of reintegration into the workplace. Further naturalistic studies are needed to test the transferability of the effectiveness of these treatments to other disorders.

'A factory of therapy': accountability and the monitoring of psychological therapy in IAPT

Since the introduction of the Improving Access to Psychological Therapies (IAPT) programme in NHS England, psychological therapy has gained traction as 'evidence-based' and 'effective' in both clinical and economic terms. In the process, psychotherapeutic care has been reconstituted as highly manualised, standardised, and quantifiable. Drawing on anthropological fieldwork with mental health practitioners, this paper examines some common tensions that practitioners experience in their daily work where psychotherapy is sought within the framework of evidence-based medicine (EBM). For therapists working within IAPT, extensive monitoring and practices of accountability have come to undermine psychotherapeutic efforts to care for patients as 'people'. As a result, many practitioners now feel that they are working in a 'factory of therapy' whereby psychological treatment is recast in the service of outcome measures, and by which critique of the IAPT service, as well as caring relations within it, have been precluded.

Empirical examination of long-term and intensive psychodynamic psychotherapy for severely disturbed patients

OBJECTIVES

This study examines the effectiveness and efficiency of intensive psychodynamic psychotherapy for severely impaired patients.

METHOD

104 patients in four public mental health centers underwent intensive psychodynamic psychotherapy. The number and duration of psychiatric hospitalizations were monitored for these patients from one year before therapy to eight years after. Several outcome variables were measured every six months, six times in total over two and a half years, using a longitudinal design. A multi-level analytic approach was applied to account for repeated measurements and missing data.

RESULTS

Significant improvement was found in all three symptomatic outcome measures (SCL-90, OQ-45, BDI) throughout treatment. The numbers of psychiatric hospitalizations and psychiatric hospitalization days decreased significantly from the level they were in the year before the start of psychodynamic treatment to three years after the start of treatment. These results were maintained for at least up to eight years. After capitalization, the overall cumulative 127.47-day decrease in hospitalization days equals savings of 115,850 NIS. The average cost of treatment after capitalization was 26,770 NIS. The insurer's estimated direct savings is 89,080 NIS (24,054 $).

CONCLUSION

These findings support the hypothesis that psychodynamic psychotherapy is clinically effective and economically efficient for severely impaired patients.

Integrated Mental Healthcare and Vocational Rehabilitation for People on Sick Leave with Anxiety or Depression: 24-Month Follow-up of the Randomized IBBIS Trial

Integration of vocational rehabilitation and mental healthcare has shown some effect on work participation at 1-year follow-up after sick leave with depression and anxiety. We aimed to study the effect on work and health outcomes at 2-year follow-up, why we performed a randomized trial was conducted to study the effectiveness of integrated intervention (INT) compared to service as usual (SAU) and best practice mental healthcare (MHC). We included 631 participants, and at 24-month follow-up, we detected no differences in effect between INT and SAU. Compared to MHC, INT showed faster return-to-work (RTW) rates (p = 0.044) and a higher number of weeks in work (p = 0.024). No symptom differences were observed between the groups at 24 months. In conclusion, compared to SAU, INT was associated with a slightly higher work rate reaching borderline statistical significance at 12-month follow-up and lower stress levels at 6-month follow-up. The disappearance of relative effect between 12 and 24 months may be explained by the fact that the intervention lasted less than 12 months or by delayed spontaneous remission in the SAU group after 12 months. Despite the lack of effect at long-term follow-up, INT still performed slightly better than SAU overall. Moderate implementation difficulties, may partly explain the absence of the hypothesized effect. Integrated intervention, as implemented in this trial, showed some positive effects on mid-term vocational status and short-term stress symptom levels. However, these effects were not sustained beyond the duration of the intervention.

Implementing a revised online screening tool in a routine care online clinic treating anxiety and depression

Introduction

The ItFits implementation toolkit was developed as part of the ImpleMentAll EU Project, to help guide implementation processes. The ItFits toolkit was tested in the online clinic, Internetpsykiatrien, in the Region of Southern Denmark, where it was employed to optimize screening and intake procedures. We hypothesized that a larger proportion of assessed patients would be referred to treatment. Further, we hypothesized the completion rate and effectiveness would increase, as a result of including a more relevant sample.

Method

Using the ItFits-toolkit, Internetpsykiatrien developed a revised online screening tool. Data on patient flow and symptom questionnaires was extracted from Internetpsykiatrien six months prior to- and six months after implementation of the revised online screening tool.

Results

A total of 1,830 applicants self-referred for treatment during the study period. A significantly lower proportion of patients were referred to treatment after implementation of the revised screening tool (pre-implementation, n = 1,009; post-implementation, n = 821; odds ratio 0.67, 95% CI: 0.51; 0.87). The number of patients that completed treatment increased significantly (pre-implementation: 136/275 [49.45%], post-implementation, n = 102/162 [62.96%]; odds ratio 1.79, 95% CI 1.20; 2.70). The treatment effect was unchanged (B = 0.01, p = .996). Worth noting, the number of patients that canceled their appointment for the video assessment interview decreased drastically.

Conclusion

By using the ItFits toolkit for a focused and structured implementation effort, the clinic was able to improve the completion rate, which is an important effect in iCBT. However, contrary to our hypotheses, we did not find an increase in clinical effect, nor a larger ratio being referred to treatment after assessment. The decreased number of referrals for treatment could be a result of increased awareness of inclusion criteria among the clinicians.

The role of implementation organizations in scaling evidence-based psychosocial interventions

BACKGROUND

To bring evidence-based interventions (EBIs) to individuals with behavioral health needs, psychosocial interventions must be delivered at scale. Despite an increasing effort to implement effective treatments in communities, most individuals with mental health and behavioral problems do not receive EBIs. We posit that organizations that commercialize EBIs play an important role in disseminating EBIs, particularly in the USA. The behavioral health and implementation industry is growing, bringing the implementation field to an important inflection point: how to scale interventions to improve access while maintaining EBI effectiveness and minimizing inequities in access to psychosocial intervention.

MAIN BODY

We offer a first-hand examination of five illustrative organizations specializing in EBI implementation: Beck Institute for Cognitive Behavioral Therapy; Incredible Years, Inc.; the PAXIS Institute; PracticeWise, LLC; and Triple P International. We use the Five Stages of Small Business Growth framework to organize themes. We discuss practical structures (e.g., corporate structures, intellectual property agreements, and business models) and considerations that arise when trying to scale EBIs including balancing fidelity and reach of the intervention. Business models consider who will pay for EBI implementation and allow organizations to scale EBIs.

CONCLUSION

We propose research questions to guide scaling: understanding the level of fidelity needed to maintain efficacy, optimizing training outcomes, and researching business models to enable organizations to scale EBIs.

Variations by ethnicity in referral and treatment pathways for IAPT service users in South London

BACKGROUND

The Improving Access to Psychological Therapies (IAPT) programme aims to provide equitable access to therapy for common mental disorders. In the UK, inequalities by ethnicity exist in accessing and receiving mental health treatment. However, limited research examines IAPT pathways to understand whether and at which points such inequalities may arise.

METHODS

This study examined variation by ethnicity in (i) source of referral to IAPT services, (ii) receipt of assessment session, (iii) receipt of at least one treatment session. Routine data were collected on service user characteristics, referral source, assessment and treatment receipt from 85 800 individuals referred to South London and Maudsley NHS Foundation Trust IAPT services between 1st January 2013 and 31st December 2016. Multinomial and logistic regression analysis was used to assess associations between ethnicity and referral source, assessment and treatment receipt. Missing ethnicity data (18.5%) were imputed using census data and reported alongside a complete case analysis.

RESULTS

Compared to the White British group, Black African, Asian and Mixed ethnic groups were less likely to self-refer to IAPT services. Black Caribbean, Black Other and White Other groups are more likely to be referred through community services. Almost all racial and minority ethnic groups were less likely to receive an assessment compared to the White British group, and of those who were assessed, all racial and ethnic minority groups were less likely to be treated.

CONCLUSIONS

Racial and ethnic minority service users appear to experience barriers to IAPT care at different pathway stages. Services should address potential cultural, practical and structural barriers.

At-home, sublingual ketamine telehealth is a safe and effective treatment for moderate to severe anxiety and depression: Findings from a large, prospective, open-label effectiveness trial

BACKGROUND

At-home Ketamine-assisted therapy (KAT) with psychosocial support and remote monitoring through telehealth platforms addresses access barriers, including the COVID-19 pandemic. Large-scale evaluation of this approach is needed for questions regarding safety and effectiveness for depression and anxiety.

METHODS

In this prospective study, a large outpatient sample received KAT over four weeks through a telehealth provider. Symptoms were assessed using the Patient Health Questionnaire (PHQ-9) for depression, and the Generalized Anxiety Disorder scale (GAD-7) for anxiety. Demographics, adverse events, and patient-reported dissociation were also analyzed. Symptom trajectories were identified using Growth Mixture Modeling, along with outcome predictors.

RESULTS

A sample of 1247 completed treatment with sufficient data, 62.8 % reported a 50 % or greater improvement on the PHQ-9, d = 1.61, and 62.9 % on the GAD-7, d = 1.56. Remission rates were 32.6 % for PHQ-9 and 31.3 % for GAD-7, with 0.9 % deteriorating on the PHQ-9, and 0.6 % on the GAD-7. Four patients left treatment early due to side effects or clinician disqualification, and two more due to adverse events. Three patient subpopulations emerged, characterized by Improvement (79.3 %), Chronic (11.4 %), and Delayed Improvement (9.3 %) for PHQ-9 and GAD-7. Endorsing side effects at Session 2 was associated with delayed symptom improvement, and Chronic patients were more likely than the other two groups to report dissociation at Session 4.

CONCLUSION

At-home KAT response and remission rates indicated rapid and significant antidepressant and anxiolytic effects. Rates were consistent with laboratory- and clinic-administered ketamine treatment. Patient screening and remote monitoring maintained low levels of adverse events. Future research should assess durability of effects.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

Ten misconceptions about trauma-focused CBT for PTSD

Therapist cognitions about trauma-focused psychological therapies can affect our implementation of evidence-based therapies for posttraumatic stress disorder (PTSD), potentially reducing their effectiveness. Based on observations gleaned from teaching and supervising one of these treatments, cognitive therapy for PTSD (CT-PTSD), ten common 'misconceptions' were identified. These included misconceptions about the suitability of the treatment for some types of trauma and/or emotions, the need for stabilisation prior to memory work, the danger of 'retraumatising' patients with memory-focused work, the risks of using memory-focused techniques with patients who dissociate, the remote use of trauma-focused techniques, and the perception of trauma-focused CBT as inflexible. In this article, these misconceptions are analysed in light of existing evidence and guidance is provided on using trauma-focused CT-PTSD with a broad range of presentations.

A continuous time meta-analysis of the relationship between conspiracy beliefs and individual preventive behavior during the COVID-19 pandemic

In several longitudinal studies, reduced willingness to show COVID-19-related preventive behavior (e.g., wearing masks, social distancing) has been partially attributed to misinformation and conspiracy beliefs. However, there is considerable uncertainty with respect to the strength of the relationship and whether the negative relationship exists in both directions (reciprocal effects). One explanation of the heterogeneity pertains to the fact that the time interval between consecutive measurement occasions varies (e.g., 1 month, 3 months) both between and within studies. Therefore, a continuous time meta-analysis based on longitudinal studies was conducted. This approach enables one to examine how the strength of the relationship between conspiracy beliefs and COVID-19 preventive behavior depends on the time interval. In total, 1035 correlations were coded for 17 samples (N = 16,350). The results for both the full set of studies and a subset consisting of 13 studies corroborated the existence of reciprocal effects. Furthermore, there was some evidence of publication bias. The largest cross-lagged effects were observed between 3 and 6 months, which can inform decision-makers and researchers when carrying out interventions or designing studies examining the consequences of new conspiracy theories.

Cost-Benefit Analysis of an Intervention in Divorced Parents: Implications for Society, Public Administrations and Family Visitation Centers

Families going through conflictive divorce processes are at increased risk of developing mental health problems. The Egokitzen program is a group intervention for parents who have undergone a divorce process, funded by the public administration. Budgetary constraints cause funding institutions to be interested in the effectiveness and economic efficiency of these programs. Therefore, the objective of this research is to carry out an efficiency analysis of the Egokitzen program, implemented by family visitation centers in Spain, through a cost-benefit analysis, to determine whether the positive impact on symptomatology (measured using CBCL and SCL-90 instruments) is translated into a positive economic impact for society. A sample of 382 parents participated. Costs will be first identified and valued; secondly, benefits achieved with the program will be identified through a prevalence analysis and, finally, the cost-benefit comparative analysis will be carried out. Additionally, a sensitivity analysis will be performed. The results obtained in the analysis indicate that for every euro spent on this program, the public administration and society save 3.10 euros in future interventions through medical costs and productivity losses. The study has practical implications for public administration, organizations, and the family visitation centers that implement the program.

Breaking out of the citadel: social theory and psychiatry

British psychiatry has tended to hold itself aloof from social theory. Nonetheless, these ideas have influenced the development of mental health services. Alongside this, the biopsychosocial model cannot reconcile contradictions in the scientific evidence regarding mental illness. We need to develop a more constructive understanding of the implications of social theory.

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.

Acceptability, effectiveness and cost-effectiveness of blended cognitive-behavioural therapy (bCBT) versus face-to-face CBT (ftfCBT) for anxiety disorders in specialised mental health care: A 15-week randomised controlled trial with 1-year follow-up

BACKGROUND

Anxiety disorders are highly prevalent and cause substantial economic burden. Blended cognitive-behavioural therapy (bCBT), which integrates Internet-based CBT and face-to-face CBT (ftfCBT), is an attractive and potentially cost-saving treatment alternative to conventional CBT for patients with anxiety disorders in specialised mental health care. However, little is known about the effectiveness of bCBT in routine care. We examined the acceptability, effectiveness and cost-effectiveness of bCBT versus ftfCBT in outpatient specialised care to patients with panic disorder, social anxiety disorder and generalised anxiety disorder.

METHODS AND FINDINGS

Patients with anxiety disorders were randomised to bCBT (n = 52) or ftfCBT (n = 62). Acceptability of bCBT and ftfCBT were evaluated by assessing treatment preference, adherence, satisfaction and therapeutic alliance. Costs and effects were assessed at post-treatment and one-year follow-up. Primary outcome measure was the Beck Anxiety Inventory (BAI). Secondary outcomes were depressive symptoms, general psychopathology, work and social adjustment, quality of life and mastery. Incremental cost-effectiveness ratios (ICERs) were computed from societal and healthcare perspectives by calculating the incremental costs per incremental quality-adjusted life year (QALY). No significant differences between bCBT and ftfCBT were found on acceptability or effectiveness measures at post-treatment (Cohen's d between-group effect size on BAI = 0.15, 95% CI -0.30 to 0.60) or at one-year follow-up (d = -0.38, 95% CI -0.84 to 0.09). The modelled point estimates of societal costs (bCBT €10945, ftfCBT €10937) were higher and modelled point estimates of direct medical costs (bCBT €3748, ftfCBT €3841) were lower in bCBT. The acceptability curves showed that bCBT was expected to be a cost-effective intervention. Results should be carefully interpreted due to the small sample size.

CONCLUSIONS

bCBT appears an acceptable, clinically effective and potentially cost-saving alternative option for treating patients with anxiety disorders. Trials with larger samples are needed to further investigate cost-effectiveness.

TRIAL REGISTRATION

Netherlands Trial Register: NTR4912.

Mental Health Conditions Among Community College Students: A National Study of Prevalence and Use of Treatment Services

OBJECTIVE

This study estimated the prevalence of self-reported symptoms of mental health problems and treatment utilization in a U.S. national sample of community college students and made comparisons with data from a sample of students at 4-year educational institutions.

METHODS

The study used data for 2016-2019 from the Healthy Minds Study, an annual cross-sectional survey. The sample included 10,089 students from 23 community colleges and 95,711 students from 133 4-year institutions. Outcomes were mental health symptom prevalence based on validated screening tools and rates of service utilization, such as use of therapy and psychotropic medication. Analyses were weighted by using survey nonresponse weights.

RESULTS

Prevalence rates were comparably high in the sample of community college and 4-year students, with just more than 50% of each group meeting criteria for one or more mental health problems. Analyses by age group revealed significantly higher prevalence for community college students ages 18-22 years, relative to their same-age peers at 4-year institutions. Community college students, particularly those from traditionally marginalized backgrounds, were significantly less likely to have used services, compared with students on 4-year campuses. Financial stress was a strong predictor of mental health outcomes, and cost was the most salient treatment barrier in the community college sample.

CONCLUSIONS

This is the largest known study to report on the mental health needs of community college students in the United States. Findings have important implications for campus policies and programs and for future research to advance equity in mental health and other key outcomes, such as college persistence and retention.

Socio-economic consequences of mental distress: quantifying the impact of self-reported mental distress on the days of incapacity to work and medical costs in a two-year period: a longitudinal study in Germany

BACKGROUND

Mental disorders are related to high individual suffering and significant socio-economic burdens. However, it remains unclear to what extent self-reported mental distress is related to individuals' days of incapacity to work and their medical costs. This study aims to investigate the impact of self-reported mental distress for specific and non-specific days of incapacity to work and specific and non-specific medical costs over a two-year span.

METHOD

Within a longitudinal research design, 2287 study participants' mental distress was assessed using the Hospital Anxiety and Depression Scale (HADS). HADS scores were included as predictors in generalized linear models with a Tweedie distribution with log link function to predict participants' days of incapacity to work and medical costs retrieved from their health insurance routine data during the following two-year period.

RESULTS

Current mental distress was found to be significantly related to the number of specific days absent from work and medical costs. Compared to participants classified as no cases by the HADS (2.6 days), severe case participants showed 27.3-times as many specific days of incapacity to work in the first year (72 days) and 10.3-times as many days in the second year (44 days), and resulted in 11.4-times more medical costs in the first year (2272 EUR) and 6.2-times more in the second year (1319 EUR). The relationship of mental distress to non-specific days of incapacity to work and non-specific medical costs was also significant, but mainly driven from specific absent days and specific medical costs. Our results also indicate that the prevalence of presenteeism is considerably high: 42% of individuals continued to go to work despite severe mental distress.

CONCLUSIONS

Our results show that self-reported mental distress, assessed by the HADS, is highly related to the days of incapacity to work and medical costs in the two-year period. Reducing mental distress by improving preventive structures for at-risk populations and increasing access to evidence-based treatments for individuals with mental disorders might, therefore, pay for itself and could help to reduce public costs.

Virtual Reality-Assisted Cognitive Behavioral Therapy for Anxiety Disorders: A Systematic Review and Meta-Analysis

Objective: We aim to explore the effectiveness of virtual reality-assisted cognitive behavioral therapy (VRCBT) in the treatment of anxiety and depression in patients with anxiety disorders. We further compare the therapeutic effect of VRCBT with that of standard cognitive behavioral therapy (CBT), as well as investigate the long-term efficacy of VRCBT. Methods: As of March 3, 2020, a total of four databases (Web of Science, PubMed, PsycINFO, and Scopus) were retrieved, and two researchers independently conducted literature retrieval and research selection and performed data extraction. Methodological quality assessment was performed using the Cochrane risk of bias tool and Grading of Recommendation, Assessment, Development, and Evaluation tool (GRADE). Results: A total of 11 studies were included (n = 626; range, 25.3-43.8), and six randomized controlled trials were quantitatively analyzed. The main outcome was anxiety and depression, and the secondary outcome was the withdrawal rate and long-term effects. Meta-analysis showed that the therapeutic effect of VRCBT on anxiety was better than that of the waiting list group (WLG) (SMD = -0.92; 95% CI: -1.34, -0.50; p = 0.005, I ² = 66%, n = 276), while the therapeutic effect of VRCBT on anxiety was similar to that of standard CBT treatment (SMD = -0.26; 95% CI: -0.50, -0.01; p = 0.77, I ² = 0%, n = 150). We further found that the therapeutic effect of VRCBT on depression was better than that of the WLG (SMD = -1.29; 95% CI: -2.26, -0.32; p = 0.09, I ² = 58%, n = 74), while the effect of VRCBT was similar to that of standard CBT (SMD = -0.30; 95% CI: -0.67, -0.07; p = 0.39, I ² = 1%, n = 116). Of the five studies that reported withdrawal rates of patients during the VRCBT and CBT treatment process, the withdrawal rates of the VRCBT group and CBT group did not reach statistical significance (OR = 0.70, 1.48, p > 0.05); only two studies reported the long-term effectiveness of VRCBT in anxiety and depression on patients with anxiety disorders. Conclusion: VRCBT treatment has a specific positive effect on patients with anxiety disorders (anxiety and depression). Compared with standard CBT, similar therapeutic effects can be achieved in the treatment of anxiety disorders. However, limited randomized controlled trials were included, requiring that these results be treated with caution.

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.

Clinical effectiveness and cost effectiveness of individual mental health workers colocated within primary care practices: a systematic literature review

OBJECTIVES

Mental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been proposed as one possible solution, but evidence of clinical and cost effectiveness of this approach is unclear. We reviewed the clinical and cost effectiveness of mental health workers colocated within primary care practices.

DESIGN

Systematic literature review.

DATA SOURCES

We searched the Medline, Embase, PsycINFO, Healthcare Management Information Consortium (HMIC) and Global Health databases.

ELIGIBILITY CRITERIA

All quantitative studies published before July 2019 were eligible for the review; participants of any age and gender were included. Studies did not need to report a certain outcome measure or comparator in order to be eligible.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a standardised table; however, pooled analysis proved unfeasible. Studies were assessed for risk of bias using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool and the Cochrane collaboration's tool for assessing risk of bias in randomised trials.

RESULTS

Fifteen studies from four countries were included. Mental health worker integration was associated with mental health benefits to varied populations, including minority groups and those with comorbid chronic diseases. Furthermore, the interventions were correlated with high patient satisfaction and increases in specialist mental health referrals among minority populations. However, there was insufficient evidence to suggest clinical outcomes were significantly different from usual general practitioner care.

CONCLUSIONS

While there appear to be some benefits associated with mental health worker integration in primary care practices, we found insufficient evidence to conclude that an onsite primary care mental health worker is significantly more clinically or cost effective when compared with usual general practitioner care. There should therefore be an increased emphasis on generating new evidence from clinical trials to better understand the benefits and effectiveness of mental health workers colocated within primary care practices.

Psychodynamic psychotherapy is associated with sustained reduction in health care utilization and cost

Our objective was to examine the effectiveness and efficiency of psychodynamic psychotherapy on the reduction in health care utilization and cost while controlling for age, gender, and year. Health care utilization and cost were examined yearly in 1,675 patients from 2 years before outpatient psychotherapy (i.e., baseline) to three consecutive years after psychotherapy in a naturalistic longitudinal design. A multilevel analytic approach (LMLM) was applied to account for repeated measures effect and missing data. In the year prior to psychotherapy, there was a significant increase in total cost compared with baseline (14.8%) and in use of health care services (primary and specialist doctors' visits and outsourced referrals). In the first year following therapy, there was a significant decrease in total cost (10%) and in use of health care services (all doctors' visits, imaging, and outsourced referrals). The decrease was to baseline levels or lower and was maintained for two additional years. Psychiatric medication usage increased significantly after psychotherapy and remained so. The overall cumulative decrease in total cost per patient over 3 years after therapy was 3,665.92 NIS, equalling a 69% average cost of psychotherapy. Further cost saving can be expected due to the reduction in sick leave, disability, and psychiatric hospitalization. These findings support the notion that providing outpatient psychodynamic psychotherapy can be financially beneficial to health care systems, although further research is required for causal inferences. Also, an increase in health care utilization along with scarce physical findings may indicate unaddressed psychological distress and warrant referral for mental assessment and possible psychotherapy.

How expensive are post-traumatic stress disorders? Estimating incremental health care and economic costs on anonymised claims data

BACKGROUND

Post-traumatic stress disorders (PTSD) pose a high burden for individuals and societies. Although prevalence rates are rather low, high co-occurrence rates and overall impairments cause deleterious suffering and significant costs. Still, no long-term data on costs and trends in cost developments are available.

METHODS

Claims data from a German research database were analysed regarding direct and indirect costs occurring for individuals with incident diagnoses of PTSD. Results were compared to non-exposed average insurants matched on age and gender. Costs were analysed over a 5-year period from 2 years preceding until 3 years following an incident diagnosis of PTSD.

RESULTS

Overall costs for PTSD account for approximately 43,000 EUR per individual, which is three times higher than costs for non-exposed controls. Of these costs, 59% are caused by mental disorders, 18% specifically by PTSD. In the control group, costs for mental disorders account for 19% of total costs. Costs increase by 142% in the year after an incident diagnosis of PTSD but return to the initial level 2 years later. Still, costs are at least twice as high in every year as in those for the comparison group.

CONCLUSIONS

Individuals with PTSD seem to suffer from far more impairments in their general health conditions and incur many more costs than average insurants. Most of these seem to be caused by co-occurring mental disorders and show their maximum in the index year. Nevertheless, as costs decrease to their initial level, treatments seem to have counterbalanced the impairments due to PTSD. Thus, treatments for PTSD can be considered as beneficial and their cost-effectiveness should be further investigated.

Self-guided mindfulness and cognitive behavioural practices reduce anxiety in autistic adults: A pilot 8-month waitlist-controlled trial of widely available online tools

LAY ABSTRACT

Anxiety in autism is an important target for psychological therapies because it is very common and because it significantly impacts upon quality of life and well-being. Growing evidence suggests that cognitive behaviour therapies and mindfulness-based therapies can help autistic individuals learn to manage feelings of anxiety but access to such therapies remains problematic. In the current pilot study, we examined whether existing online cognitive behaviour therapy and mindfulness-based therapy self-help tools can help reduce anxiety in autistic adults. Specifically, 35 autistic adults were asked to try either an existing online cognitive behaviour therapy (n = 16) or mindfulness-based therapy (n = 19) programme while a further 19 autistic adults served as a waitlist comparison group. A first important finding was that 23 of the 35 (66%) participants who tried the online tools completed them, suggesting that such tools are, in principle, acceptable to many autistic adults. In addition, adults in the cognitive behaviour therapy and mindfulness-based therapy conditions reported significant decreases in anxiety over 3 and to some extent also 6 months that were less apparent in the waitlist group of participants. On broader measures of mental health and well-being, the benefits of the online tools were less apparent. Overall, the results suggest that online self-help cognitive behaviour therapy and mindfulness-based therapy tools should be explored further as a means of providing cost-effective mental health support to at least those autistic individuals who can engage effectively with such online tools.

Prompt Mental Health Care (PMHC): work participation and functional status at 12 months post-treatment

BACKGROUND

Anxiety and depression are associated with substantial functional impairment. Prompt Mental Health Care (PMHC), the Norwegian adaptation of IAPT is currently piloted across Norway, as a means to improve access to evidence-based care for adults with anxiety disorders (including subthreshold cases) and minor to moderate depression. The aims of the current paper were to examine the change in work status and functional status from pre- to post-treatment and 12 months post-treatment among clients at the first 12 PMHC pilot sites, and whether degree of change differed across sociodemographic characteristics.

METHODS

A prospective cohort design was used, including working age clients receiving treatment between October 2014 and December 2016 (n = 1446, participation rate = 61%). Work status and functional status were self-reported, the latter by the Work and Social Adjustment Scale (WSAS). Changes in work status and WSAS score were examined through multilevel models based on maximum likelihood estimation. Likelihood ratio tests were performed to determine whether the interaction between time and the respective background variables were statistically significant.

RESULTS

A substantial increase in regular work participation was observed from pre- to post-treatment, which further had increased at 12 months post-treatment. The increase was driven by a corresponding reduction in proportion of clients working and receiving benefits (OR 0.38 [0.29-0.50] baseline to final treatment, OR = 0.19 [0.12-0.32] final treatment to 12-months post-treatment), while no statistically significant change was observed in proportion out of work. Large improvement (ES = - 0.89) in WSAS score was observed from pre- to post treatment. WSAS score at 12 months post-treatment remained at the post-treatment level.

CONCLUSIONS

Previous research has shown substantial symptom improvement among clients receiving treatment in PMHC. The current findings indicate that PMHC might also be able to aid adults struggling with mild to moderate anxiety and depression in returning to usual level of functioning. The degree to which the observed improvements are attributable to the treatment need nonetheless to be confirmed in a trial including a control group and with more complete follow-up data from registries.

Access, accountability, and the proliferation of psychological therapy: On the introduction of the IAPT initiative and the transformation of mental healthcare

Psychological therapy today plays a key role in UK public mental health. In large part, this has been through the development of the (specifically English) Improving Access to Psychological Therapies (IAPT) programme. Through IAPT, millions of citizens have encountered interventions such as cognitive behaviour therapy, largely for the treatment of depression and anxiety. This article interrogates how this national response to problems of mental ill-health - and the problematization itself - was developed, accounted for, and sustained. By imbricating economic expertise with accounts of mental ill-health and mechanisms of treatment, IAPT has revivified psychological framings of pathology and therapy. However, it has done so in ways that are more familiar within biomedical contexts (e.g. through recourse to randomized controlled trial studies). Today, the initiative is a principal player in relation to which other services are increasingly developed. Indeed, in many respects IAPT has transformed from content to context within UK public mental health (in a process of what I term 'contextification'). By documenting these developments, this paper contributes to re-centring questions about the place and role of psychology in contemporary healthcare. Doing so helps to complicate assumptions about the dominance of linear forms of (de)biomedicalization in health-systems.

Impact of a progressive stepped care approach in an improving access to psychological therapies service: An observational study

England’s national Improving Access to Psychological Therapies (IAPT) programme advocates stepped care as its organizational delivery of psychological therapies to common mental health problems. There is limited evidence regarding the efficacy of stepped care as a service delivery model, heterogeneity of definition and differences in model implementation in both research and routine practice, hence outcome comparison in terms of effectiveness of model is difficult. Despite sound evidence of the efficacy of low intensity interventions there appears to be a perpetuation of the notion that severity and complexity should only be treated by a high intensity intervention through the continuation of a stratified care model. Yet no psychotherapy treatment is found to be more superior to another, and not enough is known about what works for whom to aid the matching of treatment decision. In the absence of understanding precise treatment factors optimal for recovery, it may be useful to better understand the impact of a service delivery model, and whether different models achieve different outcomes. This study aims to contribute to the discussion regarding the stepped care definition and delivery, and explores the impact on clinical outcomes where different types of stepped care have been implemented within the same service. An observational cohort study analysed retrospective data (n = 16,723) over a 4 year period, in a single IAPT service, where delivery changed from one type of stepped care model to another. We compared the outcomes of treatment completers with a stratified care model and a progression care model. We also explored the assumption that patients who score severe on psychological measures, and therefore are potentially complex, would achieve better outcomes in a stratified model. Outcomes in each model type were compared, alongside baseline factor variables. A significant association was observed between a recovery outcome and model type, with patients 1.5 times more likely to recover in the progression delivery model. The potential implications are that with a progression stepped care model of service delivery, more patients can be treated with a lower intensity intervention, even with initial severe presentations, ensuring that only those that need high intensity CBT or equivalent are stepped up. This could provide services with an effective clinical model that is efficient and potentially more cost effective.

Expanding access to psychotherapy in Canada: Building on achievements in Australia and the United Kingdom

Australia and the United Kingdom have significantly expanded access to psychotherapy over the past decade. With this international experience to draw upon and a new $5 billion federal mental health transfer, Canada is well positioned to address long-standing gaps and inequities in access to psychotherapy. In Canada's more decentralized context, a concerted effort from health leaders at all levels of government and across multiple sectors and professions is needed to make the most of this opportunity for reform. Key priorities for health leaders include using the full range of provincial and territorial policy levers for either a grants-based or insurance-based approach; implementing a strong approach to performance monitoring, with equity targets built in from the outset; addressing gaps in workforce planning; and forming a pan-Canadian coalition for expanding access to psychotherapy.

The prevalence and treatment of mental health conditions documented in general practice in Ireland

OBJECTIVES

As prevalence of mental health disorders increases worldwide, recognition and treatment of these disorders falls increasingly into the remit of primary care. This study investigated the prevalence and management of adults presenting to their general practitioner (GP) in Ireland with a psychological condition.

METHODS

A random number function was used to select 100 patients with a consultation in the previous 2 years from 40 general practices around Ireland. The clinical records of these patients were examined using a standardised reporting tool to extract information on demographics, eligibility for free care, prevalence and treatment of psychological conditions.

RESULTS

From a sample of 3845 'active' patients, 620 (16%, 95% confidence interval 15-17%) had a documented psychological condition in the previous 2 years. The most common diagnoses were depression (54%) followed by stress and anxiety (47%). The following patient characteristics were associated with having a documented mental health condition: female gender; higher GP consultation rate; a referral or attendance at secondary care and eligibility for free GP care. Of those with a psychological condition, 34% received a psychological intervention and 81% received a pharmacological intervention.

CONCLUSIONS

The overall prevalence estimate of mental health disorders for this sample was lower than previously documented in primary care. Patients diagnosed with mental health disorders had higher utilisation of health services and pharmacological treatment was common.

Prompt mental health care, the Norwegian version of IAPT: clinical outcomes and predictors of change in a multicenter cohort study

BACKGROUND

Prompt mental health care (PMHC) is a Norwegian initiative, inspired by the English 'Improving Access to Psychological Therapy' (IAPT), aimed to provide low-threshold access to primary care treatment for persons with symptoms of anxiety and depression. The objectives of the present study are to describe the PMHC service, to examine changes in symptoms of anxiety and depression following treatment and to identify predictors of change, using data from the 12 first pilot sites.

METHODS

A prospective cohort design was used. All participants were asked to complete questionnaires at baseline, before each treatment session and at the end of treatment. Effect sizes (ES) for pre-post changes and recovery rates were calculated based on the Patient Health Questionnaire and the Generalized Anxiety Disorder scale. Multiple imputation (MI) was used in order to handle missing data. We examined predictors through latent difference score models and reported the contribution of each predictor level in terms of ES.

RESULTS

In total, N = 2512 clients received treatment at PMHC between October 2014 and December 2016, whereof 61% consented to participate. The changes from pre- to post-treatment were large for symptoms of both depression (ES = 1.1) and anxiety (ES = 1.0), with an MI-based reliable recovery rate of 58%. The reliable recovery rate comparable to IAPT based on last-observation-carried-forward was 48%. The strongest predictors for less improvement were having immigrant background (ES change depression - 0.27, ES change anxiety - 0.26), being out of work at baseline (ES change depression - 0.18, ES change anxiety - 0.35), taking antidepressants (ES change anxiety - 0.36) and reporting bullying as cause of problems (ES change depression - 0.29). Taking sleep medication did on the other hand predict more improvement (ES change depression 0.23, ES change anxiety 0.45).

CONCLUSIONS

Results in terms of clinical outcomes were promising, compared to both the IAPT pilots and other benchmark samples. Though all groups of clients showed substantial improvements, having immigrant background, being out of work, taking antidepressant medication and reporting bullying as cause stood out as predictors of poorer treatment response. Altogether, PMHC was successfully implemented in Norway. Areas for improvement of the service are discussed.

Stepped care in primary care - guided self-help and face-to-face cognitive behavioural therapy for common mental disorders: a randomized controlled trial

BACKGROUND

Common mental disorders (CMD) cause large suffering and high societal costs. Cognitive behavioural therapy (CBT) can effectively treat CMD, but access to treatment is insufficient. Guided self-help (GSH) CBT, has shown effects comparable with face-to-face CBT. However, not all patients respond to GSH, and stepping up non-responders to face-to-face CBT, could yield larger response rates. The aim was to test a stepped care model for CMD in primary care by first evaluating the effects of GSH-CBT and secondly, for non-responders, evaluating the additional effect of face-to-face CBT.

METHODS

Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia, adjustment or exhaustion disorder were included. In Step I, all patients received GSH-CBT. In Step II, non-responders were randomized to face-to-face CBT or continued GSH. The primary outcome was remission status, defined as a score below a pre-established cutoff on a validated disorder-specific scale.

RESULTS

After GSH-CBT in Step I, 40% of patients were in remission. After Step II, 39% of patients following face-to-face CBT were in remission compared with 19% of patients after continued GSH (p = 0.004). Using this stepped care model required less than six therapy sessions per patient and led to an overall remission rate of 63%.

CONCLUSIONS

Stepped care can be effective and resource-efficient to treat CMD in primary care, leading to high remission rates with limited therapist resources. Face-to-face CBT speeded up recovery compared with continued GSH. At follow-ups after 6 and 12 months, remission rates were similar in the two groups.

The Role of Practice Research Networks (PRN) in the Development and Implementation of Evidence: The Northern Improving Access to Psychological Therapies PRN Case Study

Practice research networks (PRNs) can support the implementation of evidence based practice in routine services and generate practice based evidence. This paper describes the structure, processes and learning from a new PRN in the Improving Access to Psychological Therapies programme in England, in relation to an implementation framework and using one study as a case example. Challenges related to: ethics and governance processes; communications with multiple stakeholders; competing time pressures and linking outcome data. Enablers included: early tangible outputs and impact; a collaborative approach; engaging with local research leads; clarity of processes; effective dissemination; and committed leadership.

Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials

The purpose of this study was to examine the efficacy of cognitive behavioral therapy (CBT) for anxiety-related disorders based on randomized placebo-controlled trials. We included 41 studies that randomly assigned patients (N = 2,843) with acute stress disorder, generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), panic disorder (PD), posttraumatic stress disorder (PTSD), or social anxiety disorder (SAD) to CBT or a psychological or pill placebo condition. Findings demonstrated moderate placebo-controlled effects of CBT on target disorder symptoms (Hedges' g = 0.56), and small to moderate effects on other anxiety symptoms (Hedges' g = 0.38), depression (Hedges' g = 0.31), and quality of life (Hedges' g = 0.30). Response rates in CBT compared to placebo were associated with an odds ratio of 2.97. Effects on the target disorder were significantly stronger for completer samples than intent-to-treat samples, and for individuals compared to group CBT in SAD and PTSD studies. Large effect sizes were found for OCD, GAD, and acute stress disorder, and small to moderate effect sizes were found for PTSD, SAD, and PD. In PTSD studies, dropout rates were greater in CBT (29.0%) compared to placebo (17.2%), but no difference in dropout was found across other disorders. Interventions primarily using exposure strategies had larger effect sizes than those using cognitive or cognitive and behavioral techniques, though this difference did not reach significance. Findings demonstrate that CBT is a moderately efficacious treatment for anxiety disorders when compared to placebo. More effective treatments are especially needed for PTSD, SAD, and PD.

Realizing the Mass Public Benefit of Evidence-Based Psychological Therapies: The IAPT Program

Empirically supported psychological therapies have been developed for many mental health conditions. However, in most countries only a small proportion of the public benefit from these advances. The English Improving Access to Psychological Therapies (IAPT) program aims to bridge the gap between research and practice by training over 10,500 new psychological therapists in empirically supported treatments and deploying them in new services for the treatment of depression and anxiety disorders. Currently IAPT treats over 560,000 patients per year, obtains clinical outcome data on 98.5% of these individuals, and places this information in the public domain. Around 50% of patients treated in IAPT services recover, and two-thirds show worthwhile benefits. The clinical and economic arguments on which IAPT is based are presented, along with details of the service model, how the program was implemented, and recent findings about service organization. Limitations and future directions are outlined.

Psychological therapies, older people and human rights

Additional funding has recently been made available by the government for the treatment of anxiety and depression. However, this is targeted towards people of working age, to reduce expenditure on incapacity benefit. That older people with the same mental illnesses do not receive equitable access to psychological therapies contradicts other recent government recommendations. Economic data appears to hugely influence provision of services for this group of users, but is this appropriate and humane? the Human Rights Act 1998 (Chapter 42) has been largely ignored in the provision of mental health services for older people, and the centrality of this legislation needs further consideration.

Integrated mental health care and vocational rehabilitation to improve return to work rates for people on sick leave because of depression and anxiety (the Danish IBBIS trial): study protocol for a randomized controlled trial

BACKGROUND

Depression and anxiety are among the largest contributors to the global burden of disease and have negative effects on both the individual and society. Depression and anxiety are very likely to influence the individual's work ability, and up to 40% of the people on sick leave in Denmark have depression and/or anxiety. There is no clear evidence that treatment alone will provide sufficient support for vocational recovery in this group. Integrated vocational and health care services have shown good effects on return to work in other, similar welfare contexts. The purpose of the IBBIS (Integrated Mental Health Care and Vocational Rehabilitation to Individuals on Sick Leave Due to Anxiety and Depression) interventions is to improve and hasten the process of return to employment for people in Denmark on sick leave because of depression and anxiety.

METHODS/DESIGN

This three-arm, parallel-group, randomized superiority trial has been set up to investigate the effectiveness of the IBBIS mental health care intervention and the integrated IBBIS mental health care and IBBIS vocational rehabilitation intervention for people on sick leave because of depression and/or anxiety in Denmark. The trial has an investigator-initiated multicenter design. A total of 603 patients will be recruited from Danish job centers in 4 municipalities and randomly assigned to one of 3 groups: (1) IBBIS mental health care integrated with IBBIS vocational rehabilitation, (2) IBBIS mental health care and standard vocational rehabilitation, and (3) standard mental health care and standard vocational rehabilitation. The primary outcome is register-based return to work at 12 months. The secondary outcome measures are self-assessed level of depression (Beck Depression Inventory II), anxiety (Beck Anxiety Inventory), stress symptoms (Four-Dimensional Symptom Questionnaire), work and social functioning (Work and Social Adjustment Scale), and register-based recurrent sickness absence.

DISCUSSION

This study will provide new knowledge on vocational recovery, integrated vocational and health care interventions, and prevention of recurrent sickness absence among people with depression and anxiety. If the effect on return to work is different in the intervention groups, this study can contribute to current knowledge on shared care models for health care and vocational rehabilitation services.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02872051 . Retrospectively registered on 15 August 2016.

Integrated mental health care and vocational rehabilitation to improve return to work rates for people on sick leave because of exhaustion disorder, adjustment disorder, and distress (the Danish IBBIS trial): study protocol for a randomized controlled trial

BACKGROUND

Common mental disorders are important contributors to the global burden of disease and cause negative effects on both the individual and society. Stress-related disorders influence the individual's workability and cause early retirement pensions in Denmark. There is no clear evidence that mental health care alone will provide sufficient support for vocational recovery for this group. Integrated vocational and health care services have shown good effects on return to work in other similar welfare contexts. The purpose of the Danish IBBIS (Integreret Behandlings- og BeskæftigelsesIndsats til Sygemeldte) study is to examine the efficacy of (1) a stepped mental health care intervention with individual stress coaching and/or group-based MBSR and (2) an integrated stepped mental health care with individual stress coaching and/or group-based MBSR and vocational rehabilitation intervention for people on sick leave because of exhaustion disorder, adjustment disorder or distress in Denmark.

METHOD/DESIGN

This three-armed, parallel-group, randomized superiority trial is set up to investigate the effectiveness of a stepped mental health care intervention and an integrated mental health care and vocational rehabilitation intervention for people on sick leave because of exhaustion disorder, adjustment disorder or distress in Denmark. The trial has an investigator-initiated multicenter design. Six hundred and three patients will be recruited from Danish vocational rehabilitation centers in four municipalities and randomly assigned into three groups: (1) IBBIS mental health care integrated with IBBIS vocational rehabilitation, (2) IBBIS mental health care and standard vocational rehabilitation, and (3) standard mental health care and standard vocational rehabilitation. The primary outcome is register-based return to work at 12 months. The secondary outcome measures are self-assessed level of depression (BDI), anxiety (BAI), distress symptoms (4DSQ), work- and social functioning (WSAS), and register-based recurrent sickness absence.

DISCUSSION

This study will contribute with knowledge on the consequence of the current organizational separation of health care interventions and vocational rehabilitation regarding the individual's process of returning to work after sick leave because of exhaustion disorder, adjustment disorder or distress. If the effect on return to work, symptom level, and recurrent sick leave is different in the intervention groups, this study can contribute with new knowledge on shared care models and the potential for preventing deterioration in stress symptoms, prolonged sick leave, and recurrent sick leave.

TRIAL REGISTRATION

ClinicalTrials.gov, registration number: NCT02885519 . Retrospectively registered on 15 August 2016). Participants have been included in the IBBIS trial for distress, adjustment disorder and exhaustion disorder since April 2016.

How Economic Analysis Can Contribute to Understanding the Links between Housing and Health

An economic analysis of housing's linkages to health can assist policy makers and researchers to make better decisions about which housing interventions and policies are the most cost-beneficial. The challenge is to include cobenefits. The adoption in 2015 of the UN Sustainable Development Goals underscores the importance of understanding how policies interact, and the merit of comprehensively evaluating cobenefits. We explain our approach to the empirical assessment of such cobenefits in the housing and health context, and consider lessons from empirical economic appraisals of the impact of housing on health outcomes. Critical assumptions relating to cobenefits are explicitly examined. A key finding is that when wider policy outcome measures are included, such as mental health impacts and carbon emission reductions, it is important that effects of assumptions on outcomes are considered. Another is that differing values underlie appraisal, for example, the weight given to future generations through the discount rate. Cost-benefit analyses (CBAs) can better facilitate meaningful debate when they are based on explicit assumptions about values. In short, the insights drawn from an economic framework for housing-and-health studies are valuable, but nonetheless contingent. Given that housing interventions typically have both health and other cobenefits, and incorporate social value judgements, it is important to take a broad view but be explicit about how such interventions are assessed.

Population-based cost-offset analyses for disorder-specific treatment of anorexia nervosa and bulimia nervosa in Germany

Previous research has shown that anorexia nervosa (AN) and bulimia nervosa (BN) are expensive illnesses to treat. To reduce their economic burden, adequate interventions need to be established. Our objective was to conduct cost-offset analyses for evidence-based treatment of eating disorders using outcome data from a psychotherapy trial involving cognitive behavioral therapy (CBT) and focal psychodynamic therapy (FPT) for AN and a trial involving CBT for BN. Assuming a currently running, ideal healthcare system using a 12-month, prevalence-based approach and varying the willingness to participate in treatment, we investigated whether the potential financial benefits of AN- and BN-related treatment outweigh the therapy costs at the population level. We elaborated on a formula that allows calculating cost-benefit relationships whereby the calculation of the parameters is based on estimates from data of health institutions within the German healthcare system. Additional intangible benefits were calculated with the aid of Quality-Adjusted Life Years. The annual costs of an untreated eating disorder were 2.38 billion EUR for AN and 617.69 million EUR for BN. Independent of the willingness to participate in treatment, the cost-benefit relationships for the treatment remained constant at 2.51 (CBT) and 2.33 (FPT) for AN and 4.05 (CBT) for BN. This consistency implies that for each EUR invested in the treatment, between 2.33 and 4.05 EUR could be saved each year. Our findings suggest that the implementation of evidence-based psychotherapy treatments for AN and BN may achieve substantial cost savings at the population level.

The efficacy of psychotherapy, pharmacotherapy and their combination on functioning and quality of life in depression: a meta-analysis

BACKGROUND

There is growing recognition of the importance of both functioning and quality of life (QoL) outcomes in the treatment of depressive disorders, but the meta-analytic evidence is scarce. The objective of this meta-analysis of randomized controlled trials (RCTs) was to determine the absolute and relative effects of psychotherapy, pharmacotherapy and their combination on functioning and QoL in patients with depression.

METHOD

One hundred and fifty-three outcome trials involving 29 879 participants with depressive disorders were identified through database searches in Pubmed, PsycINFO and the Cochrane Central Register of Controlled Trials.

RESULTS

Compared to control conditions, psychotherapy and pharmacotherapy yielded small to moderate effect sizes for functioning and QoL, ranging from g = 0.31 to g = 0.43. When compared directly, initial analysis yielded no evidence that one of them was superior. After adjusting for publication bias, psychotherapy was more efficacious than pharmacotherapy (g = 0.21) for QoL. The combination of psychotherapy and medication performed significantly better for both outcomes compared to each treatment alone yielding small effect sizes (g = 0.32 to g = 0.39). Both interventions improved depression symptom severity more than functioning and QoL.

CONCLUSION

Despite the small number of comparative trials for some of the analyses, this study reveals that combined treatment is superior, but psychotherapy and pharmacotherapy alone are also efficacious for improving functioning and QoL. The overall relatively modest effects suggest that future tailoring of therapies could be warranted to better meet the needs of individuals with functioning and QoL problems.

A feasibility study of the clinical effectiveness and cost-effectiveness of individual cognitive behavioral therapy for panic disorder in a Japanese clinical setting: an uncontrolled pilot study

Background

In Japan, cognitive behavioral therapy (CBT) for panic disorder (PD) is not well established. Therefore, a feasibility study of the clinical effectiveness and cost-effectiveness of CBT for PD in a Japanese clinical setting is urgently required. This was a pilot uncontrolled trial and the intervention consisted of a 16-week CBT program. The primary outcome was Panic Disorder Severity Scale (PDSS) scores. Quality of life was assessed using the EuroQol’s EQ-5D questionnaire. Assessments were conducted at baseline, 8 weeks, and at the end of the study. Fifteen subjects completed outcome measures at all assessment points.

Results

At post-CBT, the mean reduction in PDSS scores from baseline was −6.6 (95 % CI 3.80 to −9.40, p < 0.001) with a Cohen’s d = 1.77 (95 % CI 0.88–2.55). Ten (66.7 %) participants achieved a 40 % or greater reduction in PDSS. By calculating areas under the curve for EQ-5D index changes, we estimated that patients gained a minimum of 0.102 QALYs per 1 year due to the CBT.

Conclusions

This study demonstrated that individual CBT for PD may be useful in Japanese clinical settings but further randomized control trials are needed.

Trial registration: UMIN-CTR UMIN000022693 (retrospectively registered)