Group cognitive behavioural therapy for postnatal depression: a systematic review of clinical effectiveness, cost-effectiveness and value of information analyses

Interventions to Reduce Parental Substance Use, Domestic Violence and Mental Health Problems, and Their Impacts Upon Children's Well-Being: A Systematic Review of Reviews and Evidence Mapping

INTRODUCTION

Children exposed to parental intimate partner violence and abuse, mental illness, and substance use experience a range of problems which may persist into adulthood. These risks often co-occur and interact with structural factors such as poverty. Despite increasing evidence, it remains unclear how best to improve outcomes for children and families experiencing these adversities and address the complex issues they face.

AIMS AND METHODS

Systematic review of systematic reviews. We searched international literature databases for systematic reviews, from inception to 2021, to provide an evidence overview of the range and effectiveness of interventions to support children and families where these parental risk factors had been identified.

RESULTS

Sixty-two systematic reviews were included. The majority (n = 59) focused on interventions designed to address single risk factors. Reviews mostly focused on parental mental health (n = 38) and included psychological interventions or parenting-training for mothers. Only two reviews assessed interventions to address all three risk factors in combination and assessed structural interventions. Evidence indicates that families affected by parental mental health problems may be best served by integrated interventions combining therapeutic interventions for parents with parent skills training. Upstream interventions such as income supplementation and welfare reform were demonstrated to reduce the impacts of family adversity.

CONCLUSION

Most intervention approaches focus on mitigating individual psychological harms and seek to address risk factors in isolation, which presents potentially significant gaps in intervention evidence. These interventions may not address the cumulative impacts of co-occurring risks, or social factors that may compound adversities.

Adaptation and integration of the thinking healthy programme into pregnancy schools in Istanbul, Turkey

BACKGROUND

Perinatal mental health is a major public health concern. In Turkey, public hospitals operate pregnancy schools which provides an opportunity to integrate an evidence-based Thinking Healthy Programme (THP) for perinatal depression. The aim of this study is to adapt the THP for universal use in the group setting and to understand its acceptability and feasibility for integration into the existing antenatal care programme for both face-to-face and online delivery.

METHODS

Following an expert-led adaptation process using the Bernal Framework, field testing was conducted on a group of women and facilitators followed by in-depth interviews (n:8) and group discussions (n = 13). Data were analysed using Thematic Framework Analysis.

RESULTS

Minor but significant adaptations were made to the individually delivered THP for use in the universal group pregnancy schools. Initial findings indicate that the THP-group version was acceptable to its target population and could be integrated into the antenatal care plan for delivery during face-to-face and online group classes.

CONCLUSION

THP is transferable to the Turkish cultural and healthcare context. The THP-group version has the potential to add value to Turkey's existing perinatal healthcare programme.

Psychological treatment of perinatal depression: a meta-analysis

BACKGROUND

Depression during pregnancy and after the birth of a child is highly prevalent and an important public health problem. Psychological interventions are the first-line treatment and, although a considerable number of randomized trials have been conducted, no recent comprehensive meta-analysis has evaluated treatment effects.

METHODS

We used an existing database of randomized controlled trials of psychotherapies for adult depression and included studies aimed at perinatal depression. Random effects models were used in all analyses. We examined the effects of the interventions in the short and long term, and also examined secondary outcomes.

RESULTS

Forty-three studies with 49 comparisons and 6270 participants between an intervention and control group were included. The overall effect size was g = 0.67 [95% confidence interval (CI) 0.45~0.89; numbers needed-to-be-treated = 4.39] with high heterogeneity (I² = 80%; 95% CI 75~85). This effect size remained largely unchanged and significant in a series of sensitivity analyses, although some publication bias was found. The effects remained significant at 6-12 months follow-up. Significant effects were also found for social support, anxiety, functional limitations, parental stress and marital stress, although the number of studies for each outcome was low. All results should be considered with caution because of the high levels of heterogeneity in most analyses.

CONCLUSIONS

Psychological interventions are probably effective in the treatment of perinatal depression, with effects that last at least up to 6-12 months and probably also have effects on social support, anxiety, functional impairment, parental stress, and marital stress.

In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: a randomized controlled trial

BACKGROUND

Postpartum depression (PPD) affects up to one in five mothers and birthing parents, yet as few as 10% access evidence-based treatment. One-day cognitive behavioral therapy (CBT)-based workshops for PPD have the potential to reach large numbers of sufferers and be integrated into stepped models of care.

METHODS

This randomized controlled trial of 461 mothers and birthing parents in Ontario, Canada with Edinburgh Postnatal Depression Scale (EPDS) scores ⩾10, age ⩾18 years, and an infant <12 months of age compared the effects of a 1-day CBT-based workshop plus treatment as usual (TAU; i.e. care from any provider(s) they wished) to TAU alone at 12-weeks post-intervention on PPD, anxiety, the mother-infant relationship, offspring behavior, health-related quality of life, and cost-effectiveness. Data were collected via REDCap.

RESULTS

Workshops led to meaningful reductions in EPDS scores (m = 15.77 to 11.22; b = -4.6, p < 0.01) and were associated with three times higher odds of a clinically significant decrease in PPD [odds ratio (OR) 3.00, 95% confidence interval (CI) 1.93-4.67]. Anxiety also decreased and participants had three times the odds of clinically significant improvement (OR 3.20, 95% CI 2.03-5.04). Participants reported improvements in mother-infant bonding, infant-focused rejection and anger, and effortful control in their toddlers. The workshop plus TAU achieved similar quality-adjusted life-years at lower costs than TAU alone.

CONCLUSIONS

One-day CBT-based workshops for PPD can lead to improvements in depression, anxiety, and the mother-infant relationship and are cost-saving. This intervention could represent a perinatal-specific option that can treat larger numbers of individuals and be integrated into stepped care approaches at reasonable cost.

Mathematical Model of Interaction of Therapist and Patients with Bipolar Disorder: A Systematic Literature Review

Mood swings in patients with bipolar disorder (BD) are difficult to control and can lead to self-harm and suicide. The interaction between the therapist and BD will determine the success of therapy. The interaction model between the therapist and BD begins by reviewing the models that were previously developed using the Systematic Literature Review and Bibliometric methods. The limit of articles used was sourced from the Science Direct, Google Scholar, and Dimensions databases from 2009 to 2022. The results obtained were 67 articles out of a total of 382 articles, which were then re-selected. The results of the selection of the last articles reviewed were 52 articles. Using VOSviewer version 1.6.16, a visualization of the relationship between the quotes “model”, “therapy”, “emotions”, and “bipolar disorder” can be seen. This study also discusses the types of therapy that can be used by BD, as well as treatment innovations and the mathematical model of the therapy itself. The results of this study are expected to help further researchers to develop an interaction model between therapists and BD to improve the quality of life of BD.

Motherhood and Me (Mom-Me): The Development of an Acceptance-Based Group for Women with Postpartum Mood and Anxiety Symptoms

Untreated postpartum mood and anxiety disorders (PMADs) place women and their families at risk for negative biopsychosocial sequelae. Innovative and tailored treatments are needed to address potential disruptions in maternal functioning. Third-wave cognitive-behavioral approaches, including acceptance and commitment therapy (ACT) and dialectical behavioral therapy (DBT), hold promise for optimizing functioning given the focus on values-based living, rather than symptom reduction.

PURPOSE

The purpose of this paper is to describe the development of an innovative psychotherapy group for women with symptoms of PMADs.

METHODS

This seven-session group, Motherhood and Me (Mom-Me), includes selected skills training from ACT, DBT, and Emotion-Centered Problem-Solving Therapy.

RESULTS

Mom-Me group sessions are described, and an outline of key information (session goals, content, and homework assignments) is provided to facilitate practical implementation.

CONCLUSION

In line with third-wave approaches, this group was developed to enhance maternal functioning, which, in turn, may help women cope with psychological distress during the transition to motherhood.

Depression interventions for individuals with coronary artery disease - Cost-effectiveness calculations from an Irish perspective

BACKGROUND

A substantial proportion of individuals with coronary artery disease experience moderate or severe acute depression that requires treatment. We assessed the cost-effectiveness of four interventions for depression in individuals with coronary artery disease.

METHODS

We assessed effectiveness of pharmacotherapy, psychotherapy, collaborative care and exercise as remission rate after 8 and 26 weeks using estimates from a recent network meta-analysis. The cost assessment included standard doses of antidepressants, contact frequency, and staff time per contact. Unit costs were calculated as health services' purchase price for pharmaceuticals and mid-point staff salaries obtained from the Irish Health Service Executive and validated by clinical staff. Incremental cost-effectiveness ratios were calculated as the incremental costs over incremental remissions compared to usual care. High- and low-cost scenarios and sensitivity analysis were performed with changed contact frequencies, and assuming individual vs. group psychotherapy or exercise.

RESULTS

After 8 weeks, the estimated incremental cost-effectiveness ratio was lowest for group exercise (€526 per remission), followed by pharmacotherapy (€589), individual psychotherapy (€3117) and collaborative care (€4964). After 26 weeks, pharmacotherapy was more cost-effective (€591) than collaborative care (€7203) and individual psychotherapy (€9387); no 26-week assessment for exercise was possible. Sensitivity analysis showed that group psychotherapy could be most cost-effective after 8 weeks (€519) and cost-effective after 26 weeks (€1565); however no group psychotherapy trials were available investigating its effectiveness.

DISCUSSION

Large variation in incremental cost-effectiveness ratios was seen. With the current assumptions, the most cost-effective depression intervention for individuals with coronary artery disease after 8 weeks was group exercise.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Appraisal of systematic reviews on interventions for postpartum depression: systematic review

BACKGROUND

Postpartum depression (PPD) is a highly prevalent mental health problem that affects parental health with implications for child health in infancy, childhood, adolescence and beyond. The primary aim of this study was to critically appraise available systematic reviews describing interventions for PPD. The secondary aim was to evaluate the methodological quality of the included systematic reviews and their conclusions.

METHODS

An electronic database search of MEDLINE, Embase, and the Cochrane Library from 2000 to 2020 was conducted to identify systematic reviews that examined an intervention for PPD. A Measurement Tool to Assess Systematic Reviews was utilized to independently score each included systematic review which was then critically appraised to better define the most effective therapeutic options for PPD.

RESULTS

Of the 842 studies identified, 83 met the a priori criteria for inclusion. Based on the systematic reviews with the highest methodological quality, we found that use of antidepressants and telemedicine were the most effective treatments for PPD. Symptoms of PPD were also improved by traditional herbal medicine and aromatherapy. Current evidence for physical exercise and cognitive behavioural therapy in treating PPD remains equivocal. A significant, but weak relationship between AMSTAR score and journal impact factor was observed (p = 0.03, r = 0.24; 95% CI, 0.02 to 0.43) whilst no relationship was found between the number of total citations (p = 0.27, r = 0.12; 95% CI, - 0.09 to 0.34), or source of funding (p = 0.19).

CONCLUSION

Overall the systematic reviews on interventions for PPD are of low-moderate quality and are not improving over time. Antidepressants and telemedicine were the most effective therapeutic interventions for PPD treatment.

Cost-effectiveness of guideline-based stepped and collaborative care versus treatment as usual for patients with depression - a cluster-randomized trial

BACKGROUND

Depression is associated with major patient burden. Its treatment requires complex and collaborative approaches. A stepped care model based on the German National Clinical Practice Guideline "Unipolar Depression" has been shown to be effective. In this study we assess the cost-effectiveness of this guideline based stepped care model versus treatment as usual in depression.

METHODS

This prospective cluster-randomized controlled trial included 737 depressive adult patients. Primary care practices were randomized to an intervention (IG) or a control group (CG). The intervention consisted of a four-level stepped care model. The CG received treatment as usual. A cost-utility analysis from the societal perspective with a time horizon of 12 months was performed. We used quality-adjusted life years (QALY) based on the EQ-5D-3L as effect measure. Resource utilization was assessed by patient questionnaires. Missing values were imputed by 'multiple imputation using chained equations' based on predictive mean matching. We calculated adjusted group differences in costs and effects as well as incremental cost-effectiveness ratios. To describe the statistical and decision uncertainty cost-effectiveness acceptability curves were constructed based on net-benefit regressions with bootstrapped standard errors (1000 replications). The complete sample and subgroups based on depression severity were considered.

RESULTS

We found no statically significant differences in costs and effects between IG and CG. The incremental total societal costs (+€5016; 95%-CI: [-€259;€10,290) and effects (+ 0.008 QALY; 95%-CI: [- 0.030; 0.046]) were higher in the IG in comparison to the CG. Significantly higher costs were found in the IG for outpatient physician services and psychiatrist services in comparison to the CG. Significantly higher total costs and productivity losses in the IG in comparison to the CG were found in the group with severe depression. Incremental cost-effectiveness ratios for the IG in comparison to the CG were unfavourable (complete sample: €627.000/QALY gained; mild depression: dominated; moderately severe depression: €645.154/QALY gained; severe depression: €2082,714/QALY gained) and the probability of cost-effectiveness of the intervention was low, except for the group with moderate depression (ICER: dominance; 70% for willingness-to-pay threshold of €50,000/QALY gained).

CONCLUSIONS

We found no evidence for cost-effectiveness of the intervention in comparison to treatment as usual.

TRIAL REGISTRATION

NCT, NCT01731717 . Registered 22 November 2012 - Retrospectively registered.

The efficacy of cognitive behavioral therapy for the treatment of antenatal depression: A systematic review

BACKGROUND

Antenatal depression affects 7-20% of pregnant women globally yet less than a fifth of such women receive adequate treatment. Cognitive behavioral therapy (CBT) is known to be effective in the treatment of depression. However, the research is more limited with regard to the antenatal period suggesting a need for clearer evidence within this field.

OBJECTIVE

To determine if CBT is effective in the treatment of antenatal depression.

METHODS

Medline, Embase, PsychINFO, CINAHL and CENTRAL were searched for studies that quantified the effectiveness of CBT in women with a confirmed diagnosis of antenatal depression. Randomised controlled trials that measured the effectiveness of CBT delivered during the antenatal period, compared to another intervention or usual care, measured using a validated depression score pre and post intervention were included.

RESULTS

Five RCTs were eligible for inclusion, all of which found a significant decrease in depression scores following CBT interventions, greater than that observed in control groups. Improvements in depressive scores were maintained long-term for participants who received CBT. Participant satisfaction with the interventions received was high.

LIMITATIONS

Studies included displayed major performance biases, and language bias is present due to exclusion of an Iranian paper.

CONCLUSION

CBT, tailored to pregnant women, is effective in the treatment of antenatal depression, with little difference in efficacy between CBT sub-types. Further large-scale RCTs are needed to confirm these hypotheses and determine the most cost-effective way of delivering CBT to pregnant women. There is also need for a specific, validated tool for assessing antenatal depression.

Group-based interventions for postpartum depression: An integrative review and conceptual model

This integrative review explores how and to what extent group-based therapy and social support interventions affect women's recovery from postpartum depression (PPD). Thirteen articles from three databases met inclusion criteria. The studies revealed that a group environment of acceptance and understanding set a foundation for women to share their experiences with PPD. As women shared challenges, wisdom, and guidance within the group, they attained positive outcomes: validation, empowerment, and improvements in depressive symptoms. An integrated conceptual model was created to depict the identified characteristics and outcomes of PPD groups; clinicians can use the model to optimize group-based PPD interventions.

Clinical effectiveness of family therapeutic interventions in the prevention and treatment of perinatal depression: A systematic review and meta-analysis

BACKGROUND

Family therapy is a potential strategy to increase family support for those suffering from perinatal depression. Family therapeutic interventions for this population typically target depressed women and their adult family members to improve family functioning and reduce depressive symptoms.

OBJECTIVE

This systematic review and meta-analysis is a synthesis of the current evidence on the usefulness of family therapy interventions in the prevention and treatment of perinatal depression and impacts on maternal depressive symptoms and family functioning.

METHODS

This study used the Cochrane Collaboration guidelines for systematic reviews and meta-analyses. Six electronic databases were searched for randomized controlled trials and cluster randomized trials. The primary outcomes included maternal depressive symptoms and family functioning.

RESULTS

Seven studies were included in the qualitative and quantitative analyses. Fixed effects models showed statistically significant reductions in depressive symptoms at post-intervention in intervention group mothers. Intervention intensity and level of family involvement moderated intervention impacts on maternal depression. A fixed effects model showed a trend in improving family functioning at post-intervention in intervention group couples.

CONCLUSION

Although a limited number of controlled trials on family therapeutic interventions for this population exist, the findings show that these types of interventions are effective in both the prevention and treatment of perinatal depression. Recommendations for future research are addressed.

SYSTEMATIC REVIEW AND META-ANALYSIS PROTOCOL REGISTRATION

PROSPERO, CRD42017075150.

Identifying and assessing the benefits of interventions for postnatal depression: a systematic review of economic evaluations

Background

Economic evaluations of interventions for postnatal depression (PND) are essential to ensure optimal healthcare decision-making. Due to the wide-ranging effects of PND on the mother, baby and whole family, there is a need to include outcomes for all those affected and to include health and non-health outcomes for accurate estimates of cost-effectiveness. This study aimed to identify interventions to prevent or treat PND for which an economic evaluation had been conducted and to evaluate the health and non-health outcomes included.

Methods

A systematic review was conducted applying a comprehensive search strategy across eight electronic databases and other sources. Full or partial economic evaluations of interventions involving preventive strategies (including screening), and any treatments for women with or at-risk of PND, conducted in OECD countries were included. We excluded epidemiological studies and those focussing on costs only. The included studies underwent a quality appraisal to inform the analysis.

Results

Seventeen economic evaluations met the inclusion criteria, the majority focused on psychological /psychosocial interventions. The interventions ranged from additional support from health professionals, peer support, to combined screening and treatment strategies. Maternal health outcomes were measured in all studies; however child health outcomes were included in only four of them. Across studies, the maternal health outcomes included were quality-adjusted-life-years gained, improvement in depressive symptoms, PND cases detected or recovered, whereas the child health outcomes included were cognitive functioning, depression, sleep and temperament. Non-health outcomes such as couples’ relationships and parent-infant interaction were rarely included. Other methodological issues such as limitations in the time horizon and perspective(s) adopted were identified, that were likely to result in imprecise estimates of benefits.

Conclusions

The exclusion of relevant health and non-health outcomes may mean that only a partial assessment of cost-effectiveness is undertaken, leading to sub-optimal resource allocation decisions. Future research should seek ways to expand the evaluative space of economic evaluations and explore approaches to integrate health and non-health outcomes for all individuals affected by this condition. There is a need to ensure that the time horizon adopted in studies is appropriate to allow true estimation of the long-term benefits and costs of PND interventions.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1738-9) contains supplementary material, which is available to authorized users.

A systematic review and meta-analysis of interpersonal psychotherapy for perinatal women

BACKGROUND

Interpersonal psychotherapy (IPT) has demonstrated efficacy for the prevention and treatment of perinatal depression. Previous systematic reviews have not evaluated the effects of IPT on other outcomes, most notably symptoms of anxiety and interpersonal functioning, or assessed moderators of treatment efficacy specific to IPT.

METHOD

A systematic review identified 28 studies assessing the efficacy of IPT during pregnancy or the first year postpartum. Random effects meta-analyses assessed the average change in outcomes (depression, anxiety, relationship quality, social adjustment, and social support) from pre- to post-treatment, the difference in the change in outcomes between treatment and comparison conditions, and the difference in prevalence of depressive episodes between treatment and comparison conditions. Study, intervention, and sample characteristics were evaluated as potential moderators of effect sizes.

RESULTS

In prevention studies, IPT was effective for reducing depressive symptoms and the prevalence of depressive episodes. In treatment studies, IPT reduced symptoms of depression and anxiety and improved relationship quality, social adjustment and social support. Few significant moderators were identified, and results of moderation analyses were inconsistent across outcomes.

LIMITATIONS

There are insufficient studies to evaluate the effects of preventive IPT on anxiety and interpersonal outcomes. Analyses of potential moderators were limited by the number of studies available for subgroup comparisons.

CONCLUSIONS

IPT is an effective preventive intervention for perinatal depression. IPT is clearly effective for treating depressive symptoms and promising as a treatment for anxiety and improving interpersonal functioning. Further research is necessary to assess whether adaptations to IPT enhance its efficacy.

Cost Effectiveness of a Community-Delivered Consultation to Improve Infant Sleep Problems and Maternal Well-Being

OBJECTIVES

To evaluate the cost effectiveness of a community-delivered consultation aimed at improving infant sleep and maternal well-being.

METHODS

A decision-analytic model was developed that compared the costs and benefits of an infant sleep consultation with usual care. The effectiveness of the consultation was based on clinical evidence, and improvements in maternal quality of life were estimated by mapping the Edinburgh Postnatal Depression Scale scores to published utility scores. Cost effectiveness was calculated as the incremental cost per quality-adjusted life-year gained (QALY).

RESULTS

The statistically significant improvements in mean Edinburgh Postnatal Depression Scale scores at 4- and 16-month follow-ups were used to estimate the benefit in terms of QALYs. The modeled results demonstrated that the infant sleep consultation is low-cost (A$ 436), more effective in terms of QALYs gained (0.017), and cost-effective. The estimated incremental cost-effectiveness ratio was A$ 4031/QALY gained. The main drivers of the model were the use of early parenting centers and nurse training costs.

CONCLUSIONS

Community-based nurse-delivered infant sleep consultations aid infant sleep, improve maternal quality of life, and are cost-effective compared with usual care and lead to improvements in quality of life through a reduction in postnatal depression.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

BACKGROUND

Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.

OBJECTIVES

To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.

DATA SOURCES

We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.

REVIEW METHODS

Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.

RESULTS

From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.

LIMITATIONS

In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.

CONCLUSIONS

Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.

FUTURE WORK RECOMMENDATIONS

Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003273.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Results of the First Steps study: a randomised controlled trial and economic evaluation of the Group Family Nurse Partnership (gFNP) programme compared with usual care in improving outcomes for high-risk mothers and their children and preventing abuse

Background

Family Nurse Partnership (FNP) is a home-based nurse home-visiting programme to support vulnerable parents. Group Family Nurse Partnership (gFNP) has similar aims and materials and was demonstrated to be feasible in implementation evaluations.

Objectives

To determine whether or not gFNP, compared with usual care, could reduce risk factors for maltreatment in a vulnerable group and be cost-effective.

Design

A multisite randomised controlled parallel-group trial and prospective economic evaluation, with eligible women allocated (minimised by site and maternal age group) to gFNP or usual care.

Setting

Community locations in the UK.

Participants

Expectant mothers aged < 20 years with one or more previous live births, or expectant mothers aged 20–24 years with no previous live births and with low educational qualifications (defined as General Certificate of Education at grade C or higher in neither mathematics nor English language or, if they had both, no more than four General Certificates of Education at grade C or higher).

Intervention

Forty-four sessions of gFNP (14 during pregnancy and 30 in the first 12 months after birth) were offered to groups of between 8 and 12 women with similar expected delivery dates (the difference between the earliest and latest expected delivery date ranged from 8 to 10 weeks depending on the group) by two family nurses (FNs), one of whom had notified her intention to practise as a midwife.

Main outcome measures

Parenting was assessed by a self-report measure of parenting opinions, the Adult Adolescent Parenting Inventory Version 2 (AAPI-2), and an objective measure of maternal sensitivity, the CARE-Index. Cost-effectiveness was primarily expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained.

Data sources

Interviews with participants at baseline and when infants were aged 2, 6 and 12 months. Cost information from nurse weekly logs and other service delivery data.

Results

In total, 166 women were enrolled (99 to the intervention group and 67 to the control group). Adjusting for site and maternal age group, the intention-to-treat analysis found no effect of gFNP on either of the primary outcomes. AAPI-2 total was 7.5/10 [standard error (SE) 0.1] in both arms [difference also adjusted for baseline 0.08, 95% confidence interval (CI) –0.15 to 0.28;p = 0.50]. CARE-Index maternal sensitivity mean: intervention 4.0 (SE 0.3); control 4.7 (SE 0.4) (difference –0.76, 95% CI –1.67 to 0.13;p = 0.21). The sensitivity analyses supported the primary analyses. The probability that the gFNP intervention was cost-effective based on the QALY measure did not exceed 3%. However, in terms ofchangein AAPI-2 score (baseline to 12 months), the probability that gFNP was cost-effective reached 25.1%. A separate discrete choice experiment highlighted the value placed by both pregnant women and members of the general population on non-health outcomes that were not included in the QALY metric.

Limitations

Slow recruitment resulted in smaller than ideal group sizes. In some cases, few or no sessions took place owing to low initial group size, and small groups may have contributed to attrition from the intervention. Exposure to gFNP sessions was below maximum for most group members, with only 58 of the 97 intervention participants receiving any sessions; FNs were experienced with FNP but were mainly new to delivering gFNP.

Conclusions

The trial does not support the delivery of gFNP as a means of reducing the risk of child abuse or neglect in this population.

Future work

A randomised controlled trial with modified eligibility to enable first-time mothers aged < 20 years to be included, and a modified recruitment strategy to enable faster identification of potential participants from antenatal medical records.

Trial registration

Current Controlled Trials ISRCTN78814904.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 5, No. 9. See the NIHR Journals Library website for further project information.

Evaluating the effectiveness of a brief group cognitive behavioural therapy intervention for perinatal depression

Little is known about the effectiveness of group cognitive behavioural therapy (CBT) in women with perinatal depression (PND) and psychiatric comorbidities. Thirty-four women with PND (sixty-two percent with comorbidity) completed a 9-week CBT group. Eighty percent showed a clinically significant improvement in depressive symptoms. Meaningful gains in social support, mother-infant bonding, and partner relationship quality were seen. Brief group CBT can be effective in the treatment of PND in women with psychiatric comorbidities and may be a less resource-intensive alternative to individual psychotherapy.

[Treatment of psychiatric disorders during pregnancy and the breast feeding : Psychotherapy and other nondrug therapies]

The majority of women suffering from psychiatric disorders in pregnancy and the breast feeding prefer psychotherapy and other nonpharmacological treatment over psychopharmacological treatment although the risk of malformations and postnatal complications in children exposed to psychopharmacological drugs must be regarded as acceptable in moderate to severely ill patients. Data are lacking, but several psychotherapeutic and biological treatments as well as noninvasive brain stimulation procedures have been investigated to treat depressive episodes and anxiety disorders in pregnancy and the breast feeding. In mild to moderate depressive episodes different psychotherapy treatments and counseling are significantly more effective in reducing depressive symptoms than no treatment.The same seems to be true for anxiety disorders; however, studies on this are sparse. Treatment by telephone and internet also seems to improve symptoms, which is of interest especially in the less flexible group of breast feeding women and for the development of future health care structures. Noninvasive stimulation treatment has been shown to be an effective nonpharmacological therapeutic option. Data for other recent noninvasive brain stimulation treatments and biological treatments as well as exercise therapy are sparse. In severe and delusional cases as well as treatment-resistant depressive episodes, electroconvulsive therapy should be considered in pregnant women. Because several patients prefer nonpharmacological therapy during this period, those should be applied if available and feasible. Regarding nonpharmacological treatment of obsessive-compulsive disorder, bipolar disorder and schizophrenia during pregnancy and the breast feeding, no recommendation can currently be given.

Chile: Acceptability of a Training Program for Depression Management in Primary Care

Background: In Chile, there are inconsistencies in the management of depression in primary care settings, and the National Depression Program, currently in effect, was implemented without a standardized training program. The objective of this study is to evaluate the acceptability of a training program on the management of depression for primary care health teams.

Methods: The study was a randomized controlled trial, and two primary centers from the Metropolitan Region of Santiago were randomly selected to carry out the intervention training program. Pre-post surveys were applied, to evaluate expectations and satisfaction with the intervention, respectively. Descriptive and content analysis was carried out.

Result: The sample consisted of 41 health professionals, 56.1% of who reported that their expectations for the intervention were met. All of the training activities were evaluated with scores higher than 6.4 (on a 1–7 scale). The trainers, the methodology, and the learning environment were considered strengths and facilitators of the program, while the limited duration of the training, the logistical problems faced during part of the program, and the lack of educational material were viewed as weaknesses.

Conclusion: The intervention was well accepted by primary health care teams. However, the clinical impact in patients still has to be evaluated.

Couple comorbidity and correlates of postnatal depressive symptoms in mothers and fathers in the first two weeks following delivery

BACKGROUND

Postnatal depression affects a significant number of parents; however, its co-occurrence in mothers and fathers has not been studied extensively. Identifying predictors and correlates of postnatal depressive symptoms can help develop effective interventions.

METHODS

Questionnaires on several socio-demographic and psychosocial factors were administered to 276 couples within two weeks after birth. Depressive symptoms in mothers and fathers were assessed using the Edinburgh Postnatal Depression Scale (EPDS). After calculating the correlation coefficient between mothers and fathers' EPDS scores, univariate and multivariate linear regression analyses were performed to identify significant correlates of postnatal depressive symptoms in mothers and fathers.

RESULTS

Prevalence of maternal and paternal postnatal depressive symptoms was 15.9% (EPDS>12) and 5.4% (EPDS>10), respectively. There was a moderate positive correlation between mothers and fathers' EPDS scores (r=.30, p<.001). Multivariate analyses indicated that parental stress was the strongest predictor for maternal and paternal postnatal depressive symptoms. Pregnancy- and birth-related distress and partners' EPDS scores were also associated with depressive symptoms in both parents. Relationship satisfaction was only inversely related with fathers' EPDS scores, while mothers' EPDS scores were additionally associated with critical life events, history of childhood violence, and birth-related physiological complaints.

LIMITATIONS

Since information about participation rates (those who declined) is unavailable, we cannot rule out sampling bias. Further, some psychosocial factors were assessed using single items.

CONCLUSION

Since co-occurrence of depressive symptoms in mothers and fathers is high, developing and evaluating postnatal depression interventions for couples may be beneficial. Interventions to reduce parenting stress may help prevent parental postnatal depression.

Randomized Trial of Psychological Interventions to Preventing Postpartum Depression among Iranian First-time Mothers

Background:

The current study was conducted to examine the effect of cognitive behavior therapy on the reduction postpartum mood disorder and increasing the self-esteem of at-risk Iranian mothers.

Methods:

In this quasi-experimental study, 135 at-risk mothers were selected from the population by means of cluster sampling and randomly assigned into one of two groups: Intervention (n = 64), or control (n = 71). The control group received usual medical care, and the intervention group received an eight sessions’ cognitive behavior program during pregnancy. Assessments were administered at two time points (pretest at the beginning of the third trimester and posttest at 2 weeks postpartum). Beck anxiety, beck depression, Edinburgh postpartum depression, (PPD) Coopersmith self-esteem, and religious attitude questionnaire were used to collect data.

Results:

The mean age of participants was 25.8 ± 3.7 years. One-third of them had either bachelor or higher degrees in education (33%). About two-third of participants were unemployment with similar distribution in both the groups (intervention = 80%, control = 83%). The majority (70%) of the participants had cesarean section deliveries. There were no statistically significant differences respects to sociodemographic characteristics between the control and intervention groups (P > 0.05). The multivariate analysis of covariance results showed that the average scores of PPD were reduced significantly in the intervention group (P < 0.001). Also while the mean score of anxiety in the intervention group decreased from 23.31 (standard error [SE] =12.11) to 16.64 (SE = 8.33) and self-esteem increased from 29.09 (SE = 3.51) to 31.81 (SE = 2.76), no change was statistically significant in comparison to the control group.

Conclusions:

According to the findings of the present study, cognitive behavior intervention is effective in reducing PPD in at-risk mothers.

A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression

BACKGROUND

Cognitive behavioral therapy (CBT) is an empirically supported treatment for treating and preventing depression that has been widely studied in perinatal populations. Previous meta-analytic reviews of CBT interventions in this population have not investigated potential moderators of treatment efficacy specific to this type of therapy.

METHOD

Forty randomized and quasi-randomized controlled trials assessing the efficacy of CBT during pregnancy and the first year postpartum were included in the meta-analyses. Change in depressive symptoms from pre-treatment to post-treatment was assessed in both treatment and prevention trials, and the difference in prevalence of postpartum depressive episodes was assessed in prevention trials. Characteristics of included studies, interventions and samples were assessed as potential moderators of effect sizes.

RESULTS

CBT interventions resulted in significant reductions in depressive symptoms compared to control conditions in both treatment and prevention studies. In prevention studies, individuals who received CBT had significantly lower rates of postpartum depressive episodes compared to control conditions. In both treatment and prevention trials, interventions initiated during the postpartum period were more effective than antenatal interventions. In prevention trials, individually-administered treatments were more effective than group interventions and greater reductions in depressive symptoms were found in studies that included higher proportions of nonwhite, single, and multiparous participants.

LIMITATIONS

The methodological quality of included studies varied widely among studies eligible for inclusion in the meta-analysis.

CONCLUSIONS

There is strong evidence that CBT interventions are effective for treating and preventing depression during the perinatal period. Further methodologically rigorous studies are needed to further investigate potential moderators of treatment efficacy.

USE OF VALUE OF INFORMATION IN UK HEALTH TECHNOLOGY ASSESSMENTS

Objectives: The aim of this study was to identify and critically appraise the use of Value of Information (VOI) analyses undertaken as part of health technology assessment (HTA) reports in England and Wales.

Methods: A systematic review of National Institute for Health Research (NIHR) funded HTA reports published between 2004 and 2013 identified the use of VOI methods and key analytical details in terms of: (i) types of VOI methodology used; (ii) parameters and key assumptions; and (iii) conclusions drawn in terms of the need for further research.

Results: A total of 512 HTA reports were published during the relevant timeframe. Of these, 203 reported systematic review and economic modeling studies and 25 of these had used VOI method(s). Over half of the twenty-five studies (n = 13) conducted both EVPI (Expected Value of Perfect Information) and EVPPI (Expected Value of Partial Perfect Information) analyses. Eight studies conducted EVPI analysis, three studies conducted EVPI, EVPPI, and EVSI (Expected Value of Sampling Information) analyses and one study conducted EVSI analysis only. The level of detail reporting the methods used to conduct the VOI analyses varied.

Conclusions: This review has shown that the frequency of the use of VOI methods is increasing at a slower pace compared with the published volume of HTA reports. This review also suggests that analysts reporting VOI method(s) in HTA reports should aim to describe the method(s) in sufficient detail to enable and encourage decision-makers guiding research prioritization decisions to use the potentially valuable outputs from quantitative VOI analyses.

An integrated web-based mental health intervention of assessment-referral-care to reduce stress, anxiety, and depression in hospitalized pregnant women with medically high-risk pregnancies: a feasibility study protocol of hospital-based implementation

Background

At prevalence rates of up to 40%, rates of depression and anxiety among women with medically complex pregnancies are 3 times greater than those in community-based samples of pregnant women. However, mental health care is not a component of routine hospital-based antenatal care for medically high-risk pregnant women.

Objective

The purpose of this study is to evaluate the effectiveness and feasibility of the hospital-based implementation of a Web-based integrated mental health intervention comprising psychosocial assessment, referral, and cognitive behavioral therapy (CBT) for antenatal inpatients.

Methods

This study is a quasi-experimental design. Pregnant women are eligible to participate if they are (1) <37 weeks gestation, (2) admitted to the antenatal inpatient unit for >72 hours, (3) able to speak and read English or be willing to use a translation service to assist with completion of the questionnaires and intervention, (4) able to complete follow-up email questionnaires, (5) >16 years of age, and (6) not actively suicidal. Women admitted to the unit for induction (eg, <72-hour length of stay) are excluded. A minimum sample of 54 women will be recruited from the antenatal high-risk unit of a large, urban tertiary care hospital. All women will complete a Web-based psychosocial assessment and 6 Web-based CBT modules. Results of the psychosocial assessment will be used by a Web-based clinical decision support system to generate a clinical risk score and clinician prompts to provide recommendations for the best treatment and referral options. The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6-8 weeks postrecruitment. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence at 3-months postpartum; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. All women will complete email questionnaires at 6-8 weeks postrecruitment and 3-months postpartum. Qualitative interviews with 10-15 health care providers and 15-30 women will provide data on feasibility and acceptability of the intervention.

Results

The study was funded in September, 2014 and ethics was approved in November, 2014. Subject recruitment will begin January, 2015 and results are expected in December, 2015. Results of this study will determine (1) the effectiveness of an integrated Web-based prenatal mental health intervention on maternal and infant outcomes and (2) the feasibility of implementation of the intervention on a high-risk antenatal unit.

Conclusions

This study will provide evidence and guidance regarding the implementation of a Web-based mental health program into routine hospital-based care for women with medically high-risk pregnancies.

A meta-analysis of the risk of major affective disorder in relatives of individuals affected by major depressive disorder or bipolar disorder

BACKGROUND

To conduct a meta-analysis to estimate the incidence of major depressive disorder (MDD) and bipolar disorder (BD) in first-degree relatives (FDRs) of probands affected by MDD or BD. The risk for MDD in FDR of BD probands and vice versa is also investigated.

METHODS

A systematic review of case-control and cohort studies, which were published between 1977 and 2012; reported relative risks (RR) or odd ratios (OR) or equivalent raw data; made an explicit distinction between MDD and BD; used operational diagnostic criteria; and reported systematic proband recruitment and ascertainment of relatives. Studies were obtained by electronic MEDLINE and EMBASE searches and hand-searching. Estimates were derived from pooled data using random effects methods.

RESULTS

Of an initial sample of 241 articles, 22 were eligible for inclusion. For FDRs of one proband with MDD compared to healthy control probands, estimates for MDD were OR=2.14 (95% CI 1.72-2.67), increasing to OR=3.23 (95% CI 2.11-4.94) for two MDD probands. For FDRs of one BD proband compared to healthy control probands, estimates for BD were OR=7.92 (95% CI 2.45-25.61), and OR=6.58 (95% CI 2.64-16.43) for FDRs of two BD probands.

CONCLUSIONS

These findings support previously published data indicating strong familiality for both MDD and BD. Data will be useful in providing individuals with a family history of MDD or BPD with tailored risk estimates.

Study protocol for a randomized, controlled, superiority trial comparing the clinical and cost- effectiveness of integrated online mental health assessment-referral-care in pregnancy to usual prenatal care on prenatal and postnatal mental health and infant health and development: the Integrated Maternal Psychosocial Assessment to Care Trial (IMPACT)

BACKGROUND

Stress, depression, and anxiety affect 15 to 25% of pregnant women. However, fewer than 20% of prenatal care providers assess and treat mental health problems and fewer than 20% of pregnant women seek mental healthcare. For those who seek treatment, the lack of health system integration and existing barriers frequently prevent treatment access. Without treatment, poor prenatal mental health can persist for years and impact future maternal, child, and family well-being.

METHODS/DESIGN

The purpose of this randomized controlled trial is to evaluate the effectiveness of an integrated process of online psychosocial assessment, referral, and cognitive behavior therapy (CBT) for pregnant women compared to usual prenatal care (no formal screening or specialized care). The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6 to 8 weeks postrandomization. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. Pregnant women are eligible if they: 1) are <28 weeks gestation; 2) speak/read English; 3) are willing to complete email questionnaires; 4) have no, low, or moderate psychosocial risk on screening at recruitment; and 5) are eligible for CBT. A sample of 816 women will be recruited from large, urban primary care clinics and allocation is by computer-generated randomization. Women in the intervention group will complete an online psychosocial assessment, and those with mild or moderate depression, anxiety, or stress symptoms then complete six interactive cognitive behavior therapy modules. All women will complete email questionnaires at 6 to 8 weeks postrandomization and at 3, 6, and 12 months postpartum. Clinic-based providers and researchers conducting chart abstraction and analysis are blinded. Qualitative interviews with 8 to 10 healthcare providers and 15 to 30 intervention group women will provide data on feasibility and acceptability of the intervention. Results of this trial will determine the feasibility and effectiveness of an integrated approach to prenatal mental healthcare and the use of highly accessible computer-based psychosocial assessment and CBT on maternal, infant, and family-based outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01901796.

Is group cognitive behaviour therapy for postnatal depression evidence-based practice? A systematic review

BACKGROUND

There is evidence that psychological therapies including cognitive behaviour therapy (CBT) may be effective in reducing postnatal depression (PND) when offered to individuals. In clinical practice, this is also implemented in a group therapy format, which, although not recommended in guidelines, is seen as a cost-effective alternative. To consider the extent to which group methods can be seen as evidence-based, we systematically review and synthesise the evidence for the efficacy of group CBT compared to currently used packages of care for women with PND, and we discuss further factors which may contribute to clinician confidence in implementing an intervention.

METHODS

Seventeen electronic databases were searched. All full papers were read by two reviewers and a third reviewer was consulted in the event of a disagreement on inclusion. Selected studies were quality assessed, using the Cochrane Risk of Bias Tool, were data extracted by two reviewers using a standardised data extraction form and statistically synthesised where appropriate using the fixed-effect inverse-variance method.

RESULTS

Seven studies met the inclusion criteria. Meta-analyses showed group CBT to be effective in reducing depression compared to routine primary care, usual care or waiting list groups. A pooled effect size of d = 0.57 (95% CI 0.34 to 0.80, p < 0.001) was observed at 10-13 weeks post-randomisation, reducing to d = 0.28 (95% CI 0.03 to 0.53, p = 0.025) at 6 months. The non-randomised comparisons against waiting list controls at 10-13 weeks was associated with a larger effect size of d = 0.94 (95% CI 0.42 to 1.47, p < 0.001). However due to the limitations of the available data, such as ill-specified definitions of the CBT component of the group programmes, these results should be interpreted with caution.

CONCLUSIONS

Although the evidence available is limited, group CBT was shown to be effective. We argue, therefore, that there is sufficient evidence to implement group CBT, conditional upon routinely collected outcomes being benchmarked against those obtained in trials of individual CBT, and with other important factors such as patient preference, clinical experience, and information from the local context taken into account when making the treatment decision.

A systematic and critical review of the evolving methods and applications of value of information in academia and practice

OBJECTIVE

This article provides a systematic and critical review of the evolving methods and applications of value of information (VOI) in academia and practice and discusses where future research needs to be directed.

METHODS

Published VOI studies were identified by conducting a computerized search on Scopus and ISI Web of Science from 1980 until December 2011 using pre-specified search terms. Only full-text papers that outlined and discussed VOI methods for medical decision making, and studies that applied VOI and explicitly discussed the results with a view to informing healthcare decision makers, were included. The included papers were divided into methodological and applied papers, based on the aim of the study.

RESULTS

A total of 118 papers were included of which 50 % (n = 59) are methodological. A rapidly accumulating literature base on VOI from 1999 onwards for methodological papers and from 2005 onwards for applied papers is observed. Expected value of sample information (EVSI) is the preferred method of VOI to inform decision making regarding specific future studies, but real-life applications of EVSI remain scarce. Methodological challenges to VOI are numerous and include the high computational demands, dealing with non-linear models and interdependency between parameters, estimations of effective time horizons and patient populations, and structural uncertainties.

CONCLUSION

VOI analysis receives increasing attention in both the methodological and the applied literature bases, but challenges to applying VOI in real-life decision making remain. For many technical and methodological challenges to VOI analytic solutions have been proposed in the literature, including leaner methods for VOI. Further research should also focus on the needs of decision makers regarding VOI.

The cost-effectiveness of group cognitive behavioral therapy compared with routine primary care for women with postnatal depression in the UK

OBJECTIVE

To assess the cost-effectiveness of group cognitive behavior therapy (gCBT) in comparison with routine primary care for women with postnatal depression in the UK.

METHODS

Our analysis was based on a systematic literature review of the relative clinical effectiveness of gCBT compared with routine primary care and further reviews, supplemented with expert opinion of the likely cost of providing gCBT and the duration of comparative advantage for gCBT. Raw data were used to estimate a statistical relationship between changes in the Edinburgh Postnatal Depression Score (EPDS) values and changes in short-form six dimensions' (SF-6D) values. A mathematical model was constructed, and probabilistic sensitivity analyses were undertaken to estimate the mean cost per quality-adjusted life-year (QALY) and to evaluate the expected value of perfect information (EVPI).

RESULTS

The mean cost per QALY from the stochastic analysis was estimated to be pound36,062; however, there was considerable uncertainty around this value. The EVPI was estimated to be greater than pound64 million; the key uncertainties were in the cost per woman of providing treatment and in the statistical relationship between changes in EPDS values and changes in SF-6D values. The expected value of perfect partial information for both of these parameters was in excess of pound25 million.

CONCLUSIONS

Given the current information, the use of gCBT does not appear to be cost-effective; however, this decision is uncertain. The value of information analyses conducted indicates that further research to provide robust information on key parameters is needed and appears justified in cost-effective terms.