Cost effectiveness of guided Internet-based interventions for depression in comparison with control conditions: An individual-participant data meta-analysis

[Efficacy of internet-based interventions for depression available in Germany-A systematic review and meta-analysis]

BACKGROUND

Internet-based interventions (IBIs) for the treatment of depression have been found to have positive effects in international meta-analyses; however, it is unclear whether these effects also extend to IBIs specifically available in Germany. The aim of this meta-analysis was to estimate the immediate effects and the long-term effects of IBIs available in Germany free of charge or available on prescription and covered by the public health insurances as so-called digital health applications (DiGAs) and to compare the efficacy of DiGAs and freely available IBIs.

METHOD

A systematic literature search and random-effects meta-analysis were performed (preregistration: INPLASY202250070). Randomized controlled trials (RCTs) of IBIs freely available in Germany or as DiGA in adults with elevated depressive symptoms were compared with active and inactive controls available at the time of the survey in May 2022.

RESULTS

A total of six interventions were identified: COGITO, deprexis, iFightDepression, moodgym, Novego, and Selfapy. The pooled effect size of a total of 28 studies with 13,413 participants corresponded to an effect of Cohen's d = 0.42, (95% confidence interval, CI: 0.31-0.54, I2 = 81%). The analysis of long-term effects showed a smaller effect size of d = 0.29, (95% CI: 0.21-0.37, I2 = 22%, N = 10). Subgroup analyses indicated a possible superiority of the three interventions listed in the DiGA directory (d = 0.56, 95% CI: 0.38-0.74, I2 = 83%, N = 15) compared to the three freely available IBIs (d = 0.24, 95% CI: 0.14-0.33, I2 = 44%, N = 13, p = 0.002).

CONCLUSION

The IBIs for depressive disorders available in Germany are effective and can therefore be used in the treatment of people with a depressive disorder; however, it is possible that not all interventions are equally effective.

Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed.

OBJECTIVE

The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care.

METHODS

A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled.

RESULTS

The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95% CI -0.080 to 0.84; P=.96). The pooled incremental net benefit was US $255 (95% CI US $91 to US $419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results.

CONCLUSIONS

The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis.

TRIAL REGISTRATION

PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34.

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

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

Cost-effectiveness of varying degrees and models of therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy: Evidence from a randomized controlled trial

In routine care, Internet-delivered Cognitive Behaviour Therapy (ICBT) is often delivered with therapist support via emails/phone calls, but the cost-effectiveness of varying amounts of therapist support or having therapists specialized in ICBT is not known. This study compared the cost-effectiveness of specialized therapists providing ICBT support once-weekly (1WS) versus providing support once-weekly supplemented with a one-business-day response to patient emails (1W/1BD-S). We further compared the cost-effectiveness of 1W support offered by therapists employed in a specialized clinic (1WS) versus community clinics where therapists primarily deliver face-to-face therapy (1WC). Patients were randomly allocated to groups: 1WS group (n = 216), 1W/1BD-S group (n = 233), and 1WC group (n = 226). At baseline, 12, 24 and 52-week follow-up, patients completed the Treatment Inventory of Costs in Patients with Psychiatric Disorders questionnaire (TiC-P) adapted for use in Canada to assess healthcare use and productivity losses. Additionally, to assess Quality Adjusted Life Years (QALYs) gained, patients completed the EQ-5D-5L at the same time periods. We quantified uncertainties by one-way and probabilistic sensitivity analysis and reported Incremental cost-effectiveness ratios (ICER), cost-effectiveness planes and acceptability curves. Cost-effectiveness over 52 weeks was CAD 3072/QALY for 1WC, CAD 3244/QALY for 1W/1BD-S, and CAD 3528/QALY for 1WS. Our model suggests that 1WS is the best strategy since the incremental cost per QALY is below the $50,000 threshold (ICER is CAD 42,328/QALY compared to the next most effective, 1WC). 1W/1BD-S is dominated by the other strategies. The cost-effectiveness acceptability curves suggest that the 1WS group has a higher probability for cost-effectiveness (38 %) than 1W/1BD-S (30 %) and 1WC (32 %) when the willingness to pay is $50,000 per QALY. These results have important implications for health policymakers deciding on delivery of ICBT for the treatment of anxiety and/depressive disorders.

Cost-effectiveness of three internet-based interventions for eating disorders: A randomized controlled trial

OBJECTIVE

The primary aim was assessing the cost-effectiveness of an internet-based self-help program, expert-patient support, and the combination of both compared to a care-as-usual condition.

METHOD

An economic evaluation from a societal perspective was conducted alongside a randomized controlled trial. Participants aged 16 or older with at least mild eating disorder symptoms were randomly assigned to four conditions: (1) Featback, an online unguided self-help program, (2) chat or e-mail support from a recovered expert patient, (3) Featback with expert-patient support, and (4) care-as-usual. After a baseline assessment and intervention period of 8 weeks, five online assessments were conducted over 12 months of follow-up. The main result constituted cost-utility acceptability curves with quality-of-life adjusted life years (QALYs) and societal costs over the entire study duration.

RESULTS

No significant differences between the conditions were found regarding QALYs, health care costs and societal costs. Nonsignificant differences in QALYs were in favor of the Featback conditions and the lowest societal costs per participant were observed in the Featback only condition (€16,741) while the highest costs were seen in the care-as-usual condition (€28,479). The Featback only condition had the highest probability of being efficient compared to the alternatives for all acceptable willingness-to-pay values.

DISCUSSION

Featback, an internet-based unguided self-help intervention, was likely to be efficient compared to Featback with guidance from an expert patient, guidance alone and a care-as-usual condition. Results suggest that scalable interventions such as Featback may reduce health care costs and help individuals with eating disorders that are currently not reached by other forms of treatment.

PUBLIC SIGNIFICANCE STATEMENT

Internet-based interventions for eating disorders might reach individuals in society who currently do not receive appropriate treatment at low costs. Featback, an online automated self-help program for eating disorders, was found to improve quality of life slightly while reducing costs for society, compared to a do-nothing approach. Consequently, implementing internet-based interventions such as Featback likely benefits both individuals suffering from an eating disorder and society as a whole.

Internet- and mobile-based intervention for depression in adults with chronic back pain: A health economic evaluation

BACKGROUND

Depression and comorbid chronic back pain (CBP) lead to high personal and economic burden. Internet- and mobile-based interventions (IMI) might be a cost-effective adjunct to established interventions.

METHODS

A health economic evaluation was embedded into an observer-blinded, multicenter RCT (societal and health care perspective). We randomly assigned participants (≥18 years) with CBP and diagnosed depression from 82 orthopedic clinics across Germany to intervention (IG + treatment as usual [TAU]) or TAU control group (CG). The IG received a guided IMI. Primary outcomes were depression response and quality-adjusted life years (QALYs) at 6-months follow-up. Multiple imputation was used to address missing data. Incremental cost-effectiveness/cost-utility ratios (ICER/ICUR) and the probability of being cost-effective at different willingness-to-pay thresholds were calculated. Statistical uncertainty was estimated using bootstrapping techniques (N = 10,000).

RESULTS

Between October 2015 and July 2017 210 participants were randomly assigned to IG (n = 105) and CG (n = 105). Depression response did not differ significantly between groups. QALYs were significantly higher in the IG compared to the CG. Taking the societal perspective and assuming a commonly used willingness-to-pay of €34,000/QALY, the intervention's likelihood of being cost-effective was 64%.

LIMITATIONS

The main limitation is that the study was powered to detect clinical but not health economic differences between groups.

CONCLUSION

The IMI is considered cost-effective (vs. CG) for individuals with depression and CBP (societal perspective). These results are promising when considering the high individual and economic burden of this patient group. Further research is needed to adequately inform political decision makers before implementation into routine care.

Need for Inclusive Consideration of Transgender and Gender Diverse People in E-Health Services: A Systematic Review

Many transgender and gender diverse (TGD) people use the internet to find ways out of isolation, network, and share information on health-related topics. Thus, e-health services could reduce the health burden of TGD people and facilitate access to health care. Following the PRISMA guidelines, we conducted a systematic review on e-health approaches that could improve trans health care (i.e., services directly for TGD people or training programs for health care professionals, HCPs) and their effectiveness, acceptability, and feasibility. We searched PubMed, Web of Science, and PubPsych databases for publications from January 2000 to June 2021 with final updates before publication. The systematic review identified e-health services across 27 studies from 8 different countries. Few studies evaluated e-health services exclusively for TGD people. However, use of an e-health service was found to be effective and beneficial: TGD people improved in health-related outcomes, and HCPs improved in professional expertise. Service users find e-health services helpful and easy to integrate into their daily lives. Recommendations for further development of e-health services in trans health care are provided. In the future, given the rapidly evolving e-health research and care field, new treatment approaches for TGD people should be subject to ongoing evaluation and development.

What is the Current and Future Status of Digital Mental Health Interventions?

The prevalence of mental disorders continues to increase, especially with the advent of the COVID-19 pandemic. Although we have evidence-based psychological treatments to address these conditions, most people encounter some barriers to receiving this help (e.g., stigma, geographical or time limitations). Digital mental health interventions (e.g., Internet-based interventions, smartphone apps, mixed realities -virtual and augmented reality) provide an opportunity to improve accessibility to these treatments. This article summarizes the main contributions of the different types of digital mental health solutions. It analyzes their limitations (e.g., drop-out rates, lack of engagement, lack of personalization, lack of cultural adaptations) and showcases the latest sophisticated and innovative technological advances under the umbrella of precision medicine (e.g., digital phenotyping, chatbots, or conversational agents). Finally, future challenges related to the need for real world implementation of these interventions, the use of predictive methodology, and hybrid models of care in clinical practice, among others, are discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

The Contribution of “Individual Participant Data” Meta-Analyses of Psychotherapies for Depression to the Development of Personalized Treatments: A Systematic Review

While randomized trials typically lack sufficient statistical power to identify predictors and moderators of outcome, ”individual participant data” (IPD) meta-analyses, which combine primary data of multiple randomized trials, can increase the statistical power to identify predictors and moderators of outcome. We conducted a systematic review of IPD meta-analyses on psychological treatments of depression to provide an overview of predictors and moderators identified. We included 10 (eight pairwise and two network) IPD meta-analyses. Six meta-analyses showed that higher baseline depression severity was associated with better outcomes, and two found that older age was associated with better outcomes. Because power was high in most IPD meta-analyses, non-significant findings are also of interest because they indicate that these variables are probably not relevant as predictors and moderators. We did not find in any IPD meta-analysis that gender, education level, or relationship status were significant predictors or moderators. This review shows that IPD meta-analyses on psychological treatments can identify predictors and moderators of treatment effects and thereby contribute considerably to the development of personalized treatments of depression.

Digital interventions in mental health: evidence syntheses and economic modelling

BACKGROUND

Economic evaluations provide evidence on whether or not digital interventions offer value for money, based on their costs and outcomes relative to the costs and outcomes of alternatives.

OBJECTIVES

(1) Evaluate and summarise published economic studies about digital interventions across different technologies, therapies, comparators and mental health conditions; (2) synthesise clinical evidence about digital interventions for an exemplar mental health condition; (3) construct an economic model for the same exemplar mental health condition using the previously synthesised clinical evidence; and (4) consult with stakeholders about how they understand and assess the value of digital interventions.

METHODS

We completed four work packages: (1) a systematic review and quality assessment of economic studies about digital interventions; (2) a systematic review and network meta-analysis of randomised controlled trials on digital interventions for generalised anxiety disorder; (3) an economic model and value-of-information analysis on digital interventions for generalised anxiety disorder; and (4) a series of knowledge exchange face-to-face and digital seminars with stakeholders.

RESULTS

In work package 1, we reviewed 76 economic evaluations: 11 economic models and 65 within-trial analyses. Although the results of the studies are not directly comparable because they used different methods, the overall picture suggests that digital interventions are likely to be cost-effective, compared with no intervention and non-therapeutic controls, whereas the value of digital interventions compared with face-to-face therapy or printed manuals is unclear. In work package 2, we carried out two network meta-analyses of 20 randomised controlled trials of digital interventions for generalised anxiety disorder with a total of 2350 participants. The results were used to inform our economic model, but when considered on their own they were inconclusive because of the very wide confidence intervals. In work package 3, our decision-analytic model found that digital interventions for generalised anxiety disorder were associated with lower net monetary benefit than medication and face-to-face therapy, but greater net monetary benefit than non-therapeutic controls and no intervention. Value for money was driven by clinical outcomes rather than by intervention costs, and a value-of-information analysis suggested that uncertainty in the treatment effect had the greatest value (£12.9B). In work package 4, stakeholders identified several areas of benefits and costs of digital interventions that are important to them, including safety, sustainability and reducing waiting times. Four factors may influence their decisions to use digital interventions, other than costs and outcomes: increasing patient choice, reaching underserved populations, enabling continuous care and accepting the 'inevitability of going digital'.

LIMITATIONS

There was substantial uncertainty around effect estimates of digital interventions compared with alternatives. This uncertainty was driven by the small number of studies informing most comparisons, the small samples in some of these studies and the studies' high risk of bias.

CONCLUSIONS

Digital interventions may offer good value for money as an alternative to 'doing nothing' or 'doing something non-therapeutic' (e.g. monitoring or having a general discussion), but their added value compared with medication, face-to-face therapy and printed manuals is uncertain. Clinical outcomes rather than intervention costs drive 'value for money'.

FUTURE WORK

There is a need to develop digital interventions that are more effective, rather than just cheaper, than their alternatives.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018105837.

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. 26, No. 1. See the NIHR Journals Library website for further project information.

Efficacy of digital technologies aimed at enhancing emotion regulation skills: Literature review

BACKGROUND

The impact of emotion regulation (ER) interventions on mental health and wellbeing has been extensively documented in the literature, although only recently have digital technologies been incorporated in intervention design. The aim of this review is to explore available published literature relating to the efficacy, barriers and facilitators of digital technologies in enhancing emotion/mood regulation skills.

METHODS

A review of the literature was performed to explore the effectiveness of digital technology in enhancing ER skills. MEDLINE, CINAHL, PsycINFO and Web of Science databases were searched from inception to 31st August 2020. In addition, the first 10 pages of Google Scholar were examined for relevant articles. The following MeSH term and key words were used to identify relevant articles: "emotion regulation OR mood regulation" AND "intervention OR treatment OR program$ OR therap$" AND "digital technologies OR web-based OR mobile application OR App." Reference lists of retrieved papers were hand searched to identify additional publications. Findings were summarized narratively.

RESULTS

Titles and abstracts were reviewed by one reviewer in two phases, and confirmed by a second reviewer; discrepancies were resolved through discussion. First, the retrieved titles and abstracts were reviewed to identify relevant studies. Full texts of retrieved studies were then read to determine eligibility. The search resulted in 209 studies of which 191 citations were identified as potentially meeting the inclusion criteria. After reviewing the title and abstract of the 191 papers, 33 studies were identified as potentially meeting the inclusion criteria. Following full-text review, 10 studies met the inclusion criteria. Findings indicated the potential effectiveness of online, text-messaging, and smartphone interventions for enhancing ER skills.

CONCLUSION

There is encouraging evidence that digital technologies may be beneficial for enhancing ER skills and providing personalized care remotely. Digital technologies, particularly the use of smartphones, were instrumental in facilitating assessments and delivering online self-help interventions such as cognitive behavioral therapy. Continued research is required to rigorously evaluate the effectiveness of digital technologies in ER skills and carefully consider risks/benefits while determining how emerging technologies might support the scale-up of ER skills and mental health treatment.

Internet and Face-to-face Cognitive Behavioral Therapy for Postnatal Depression Compared With Treatment as Usual: Randomized Controlled Trial of MumMoodBooster

BACKGROUND

Previous research has confirmed that symptoms of postnatal depression (PND) can be ameliorated through internet-delivered psychological interventions. Advantages of internet-delivered treatment include anonymity, convenience, and catering to women who are unable to access face-to-face (FTF) treatments. To date, no research has examined the efficacy of such interventions compared directly with FTF treatments in women clinically diagnosed with PND.

OBJECTIVE

This study aims to compare the efficacy of one of the first web-based cognitive behavioral therapy (CBT) interventions (internet CBT+coach calls) for PND (MumMoodBooster [MMB]) with FTF-CBT in a randomized controlled trial (RCT).

METHODS

In this study, 116 postnatal women with a Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) diagnosis of major or minor depression were randomized to MMB (39/116, 33.6%), FTF-CBT (39/116, 33.6%), or a treatment-as-usual (TAU) control condition (38/116, 32.8%). Diagnostic status was determined at baseline and at 21-week follow-up using the Structured Clinical Interview for the DSM-IV. Severity of anxiety and depressive symptoms was evaluated using the Depression Anxiety Stress Scales and the revised Beck Depression Inventory at baseline, 12-week follow-up (after treatment), and 21-week follow-up.

RESULTS

Of the 116 participants, 107 (92.2%) had a diagnosis of major depression at baseline. Rates of remission from a major or minor depressive episode at 21 weeks in both the FTF-CBT and MMB groups were superior to that of the TAU group (56.6% and 47.7% less likely to be depressed, respectively) and they were not significantly different from each other. Although remission rates differed between TAU and FTF-CBT, growth models showed that, in terms of symptom reduction across time, the FTF-CBT treatment was not significantly better than TAU. By comparison, MMB was statistically superior to both TAU and FTF-CBT in reducing symptoms of depression, anxiety, and stress from baseline to the 21-week follow-up (large and moderate effect sizes). Thus, after 21 weeks, the average symptom scores for depression and anxiety of women receiving MMB were approximately half those of women in both the TAU and FTF-CBT groups.

CONCLUSIONS

In this RCT, MMB was at least as effective as FTF-CBT in achieving remission from a diagnosed PND episode. MMB was superior to TAU and FTF-CBT in encouraging and maintaining reduction of symptom severity over the 21-week follow-up for depressed postnatal women. These findings replicate results of prior studies on MMB that showed clinically significant improvements in depressive symptoms, and they provide direct empirical support that internet-delivered treatment for depressed postnatal women is a viable alternative to FTF treatment. The generalizability of the results needs to be examined in future research, as RCTs of internet-based versus FTF treatments necessarily involve a subset of people who are willing to undertake either modality of treatment.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000881730; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364683&isReview=true.

A systematic review of trial-based economic evaluations of internet- and mobile-based interventions for substance use disorders

BACKGROUND

Substance use disorders (SUDs) contribute significantly to global rates of morbidity and mortality. Internet- and mobile-based interventions (IMIs) have been suggested as an adjunct to face-to-face health services. However, the evidence for the cost-effectiveness of IMIs for SUDs is scant.

METHODS

A comprehensive literature search in PubMed, PsycINFO, the Cochrane Central Register of Controlled Trials, NHS Economic Evaluations Database, NHS Health Technology Assessment Database, Office of Health Economics Evaluations Database and EconLit was conducted. We included economic evaluations alongside randomized controlled trials of IMIs for SUDs compared with a control group.

RESULTS

Of 1687 abstracts identified, 11 studies met the inclusion criteria. Targeted conditions were alcohol use disorder (four studies) and tobacco smoking (five studies) whereas two studies included any SUD. Cost-effectiveness results demonstrated that IMIs had a firm probability of being more cost-effective than TAU (e.g. less costs per additional abstinent person). Compared with (online) psycho-education, evidence towards an additional benefit of IMIs was less clear. Regarding cost-utility (e.g. costs per quality-adjusted life year gained), except for one study, results suggested that TAU and online psycho-education would probably be more preferable than IMIs. Quality of study reporting was at least adequate.

CONCLUSIONS

The likelihood of IMIs being more cost-effective than TAU looks promising but more economic evaluations are needed in order to determine the economic merit of IMIs. With an increasing pressure on health care budgets, strategies to disseminate effective interventions at affordable costs are required. This review suggests that IMIs might carry that promise and have potential as a cost-effective strategy to scale-up existing evidence-based treatments for SUDs.

SYSTEMATIC REVIEW REGISTRATION

The systematic review has been registered in the PROSPERO database (no. CRD42018099486).

Health-economic evaluation of psychological interventions for depression prevention: Systematic review

Psychological interventions have been proven to be effective to prevent depression, however, little is known on the cost-effectiveness of psychological interventions for the prevention of depression in various populations. A systematic review was conducted using PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Econlit, NHS Economic Evaluations Database, NHS Health Technology Assessment and OpenGrey up to January 2021. Only health-economic evaluations based on randomized controlled trials of psychological interventions to prevent depression were included. Independent evaluators selected studies, extracted data and assessed the quality using the Consensus on Health Economic Criteria and the Cochrane Risk of Bias Tool. Twelve trial-based economic evaluations including 5929 participants from six different countries met the inclusion criteria. Overall, the quality of most economic evaluations was considered good, but some studies have some risk of bias. Setting the willingness-to-pay upper limit to US$40,000 (2018 prices) for gaining one quality adjusted life year (QALY), eight psychological preventive interventions were likely to be cost-effective compared to care as usual. The likelihood of preventive psychological interventions being more cost-effective than care as usual looks promising, but more economic evaluations are needed to bridge the many gaps that remain in the evidence-base. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Cost-Utility of Internet-Based Cognitive Behavioral Therapy in Unipolar Depression: A Markov Model Simulation

BACKGROUND AND OBJECTIVE

Unipolar depression is the most common form of depression and demand for treatment, such as psychotherapy, is high. However, waiting times for psychotherapy often considerably exceed their recommended maximum. As a potentially less costly alternative treatment, internet-based cognitive behavior therapy (ICBT) might help reduce waiting times. We therefore analyzed the cost-utility of ICBT compared to face-to-face CBT (FCBT) as an active control treatment, taking differences in waiting time into account.

METHODS

We constructed a Markov model to simulate costs and health outcomes measured in quality-adjusted life years (QALYs) for ICBT and FCBT in Germany. We modeled a time horizon of 3 years using six states (remission, depressed, spontaneous remission, undergoing treatment, treatment finished, death). The societal perspective was adopted. We obtained parameters for transition probabilities, depression-specific QoL, and cost data from the literature. Deterministic and probabilistic sensitivity analyses were conducted. Within a scenario analysis, we simulated different time-to-treatment combinations. Half-cycle correction was applied.

RESULTS

In our simulation, ICBT generated 0.260 QALYs and saved €2536 per patient compared to FCBT. Our deterministic sensitivity analysis suggests that the base-case results were largely unaffected by parameter uncertainty and are therefore robust. Our probabilistic sensitivity analysis suggests that ICBT is highly likely to be more effective (91.5%), less costly (76.0%), and the dominant strategy (69.7%) compared to FCBT. The scenario analysis revealed that the base-case results are robust to variations in time-to-treatment differences.

CONCLUSION

ICBT has a strong potential to balance demand and supply of CBT in unipolar depression by reducing therapist time per patient. It is highly likely to generate more QALYs and reduce health care expenditure. In addition, ICBT may have further positive external effects, such as freeing up capacities for the most severely depressed patients.

[Online therapy for depressive disorders : An acceptance-based analysis from the perspective of therapists]

BACKGROUND

The supply of online therapy options for mild to moderate depressive disorders has substantially risen both nationally and internationally in the past years. While the efficacy and efficiency of specific online-based therapeutic services were indicated within the framework of scientific evaluations, little is known about the acceptance of these new therapy options.

METHODS

In a nationwide online survey of online-based therapy options for mild to moderate depressive disorders, the attitude and stance as well as the use intention and the subjectively perceived knowledge of 657 medical practitioners and therapists, active in psychotherapeutic and psychiatric treatment were collated. The impact of the potential predictors on the use intention of online-based therapies, based on the unified theory of acceptance and use of technology, was analyzed by means of a binary logistic regression model.

RESULTS

Besides the perceived performance and expense expectations, the supportive framework conditions, the influence of the cooperative environment, the individual technical affinity as well as the evaluation of the prospective significance of online-based therapy proved to be significantly influential predictors on the user intention. Special predictability for a positive user intention was shown related to the perceived potential of online therapy.

CONCLUSION

The results underline the relevance of further evidence-basing of online therapy for mild to moderate depressive disorders. A user-oriented, participatory technology development proves to be just as relevant as a comprehensive sensitization, elucidation and education of potential users for a successful implementation.

Improving Cost-effectiveness and Access to Cognitive Behavior Therapy for Depression: Providing Remote-Ready, Computer-Assisted Psychotherapy in Times of Crisis and Beyond

INTRODUCTION

There is growing evidence that computer-delivered or computer-assisted forms of cognitive behavior therapy (CCBT) are helpful, but cost-effectiveness versus standard therapies is not well established.

OBJECTIVE

To evaluate the cost-effectiveness of a therapist-supported method for CCBT in comparison to standard cognitive behavior therapy (CBT).

METHODS

A total of 154 drug-free major depressive disorder outpatients were randomly assigned to either 16 weeks of standard CBT (up to twenty 50-min sessions) or CCBT using the Good Days Ahead program (including up to 5.5 h of therapist contact). Outcomes were assessed at baseline, weeks 8 and 16, and at 3 and 6 months post-treatment. Economic analyses took into account the costs of services received and work/social role impairment.

RESULTS

In the context of almost identical efficacy, a form of CCBT that used only about one third the amount of therapist contact as conventional CBT was highly cost-effective compared to conventional therapy and reduced the adjusted cost of treatment by USD 945 per patient.

CONCLUSIONS

A method of CCBT that blended internet-delivered modules and abbreviated therapeutic contact reduced the cost of treatment substantially without adversely affecting outcomes. Results suggest that use of this approach can more than double the access to CBT. Because clinician support in CCBT can be provided by telephone, videoconference, and/or email, this highly efficient form of treatment could be a major advance in remote treatment delivery.

Cost and Effectiveness of Blended Versus Standard Cognitive Behavioral Therapy for Outpatients With Depression in Routine Specialized Mental Health Care: Pilot Randomized Controlled Trial

BACKGROUND

Cognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability.

OBJECTIVE

This pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT.

METHODS

Patients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations.

RESULTS

Blended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95% CI -0.05 to 0.19), response to treatment (RD 0.03, 95% CI -0.10 to 0.15), and QALYs (mean difference 0.01, 95% CI -0.03 to 0.04). Mean societal costs for blended CBT were €1183 higher than standard CBT. This difference was not significant (95% CI -399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of €25,000. For health care providers, mean costs for blended CBT were €176 lower than standard CBT. This difference was not significant (95% CI -659 to 343). At €0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of €5000 for an added treatment response, and to 0.85 at €10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects.

CONCLUSIONS

This pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted.

TRIAL REGISTRATION

Netherlands Trial Register NTR4650; https://www.trialregister.nl/trial/4408.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-014-0290-z.

Targets and outcomes of psychotherapies for mental disorders: an overview

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

Exploring the Relationship Between Usage and Outcomes of an Internet-Based Intervention for Individuals With Depressive Symptoms: Secondary Analysis of Data From a Randomized Controlled Trial

Background

Internet interventions can easily generate objective data about program usage. Increasingly, more studies explore the relationship between usage and outcomes, but they often report different metrics of use, and the findings are mixed. Thus, current evaluations fail to demonstrate which metrics should be considered and how these metrics are related to clinically meaningful change.

Objective

This study aimed to explore the relationship between several usage metrics and outcomes of an internet-based intervention for depression.

Methods

This is a secondary analysis of data from a randomized controlled trial that examined the efficacy of an internet-based cognitive behavioral therapy for depression (Space from Depression) in an adult community sample. All participants who enrolled in the intervention, regardless of meeting the inclusion criteria, were included in this study. Space from Depression is a 7-module supported intervention, delivered over a period of 8 weeks. Different usage metrics (ie, time spent, modules and activities completed, and percentage of program completion) were automatically collected by the platform, and composite variables from these (eg, activities per session) were computed. A breakdown of the usage metrics was obtained by weeks. For the analysis, the sample was divided into those who obtained a reliable change (RC)—and those who did not.

Results

Data from 216 users who completed pre- and posttreatment outcomes were included in the analyses. A total of 89 participants obtained an RC, and 127 participants did not obtain an RC. Those in the RC group significantly spent more time, had more log-ins, used more tools, viewed a higher percentage of the program, and got more reviews from their supporter compared with those who did not obtain an RC. Differences between groups in usage were observed from the first week in advance across the different metrics, although they vanished over time. In the RC group, the usage was higher during the first 4 weeks, and then a significant decrease was observed. Our results showed that specific levels of platform usage, 7 hours total time spent, 15 sessions, 30 tools used, and 50% of program completion, were associated with RC.

Conclusions

Overall, the results showed that those individuals who obtained an RC after the intervention had higher levels of exposure to the platform. The usage during the first half of the intervention was higher, and differences between groups were observed from the first week. This study also showed specific usage levels associated with outcomes that could be tested in controlled studies to inform the minimal usage to establish adherence. These results will help to better understand how to use internet-based interventions and what optimal level of engagement can most affect outcomes.

Trial Registration

ISRCTN Registry ISRCTN03704676; http://www.isrctn.com/ISRCTN03704676

International Registered Report Identifier (IRRID)

RR2-10.1186/1471-244X-14-147

New Technologies for the Understanding, Assessment, and Intervention of Emotion Regulation

In the last decades, emotion regulation (ER) received increasing attention and became one of the most studied topics within the psychological field. Nevertheless, this construct has not been fully updated with the latest technological advancements. In this perspective, we will show how diverse technologies, such as virtual reality (VR), wearable biosensors, smartphones, or biofeedback techniques, can be applied to the understanding, assessment, and intervention of ER. After providing a brief overview of the currently available technological developments, we will discuss the benefits of incorporating new technologies in ER field, including ecological validity, intervention personalization, and the integration of understudied facets of ER, such as the implicit and interpersonal dimension.

Cost-utility of a guided Internet-based intervention in comparison with attention only for people with HIV and depressive symptoms: A randomized controlled trial

OBJECTIVE

The aim of this study was to evaluate the cost-utility of a guided Internet-based intervention for people living with HIV and depressive symptoms, compared to attention only (control condition). It was previously found that the intervention was effective in decreasing depressive symptoms, compared to the control group.

METHODS

This economic evaluation was conducted alongside a randomized controlled trial. The control group received attention only and was put on a waiting list. Quality adjusted life years were calculated over six months. The study was conducted from a societal perspective and included intervention costs, healthcare costs, and non-healthcare costs. Participants completed a pretest, a post-test after two to three months, and a second post-test after six months. Cost-utility acceptability curves were constructed and two sensitivity analyses were conducted.

RESULTS

No differences between the intervention and the control group were found in quality adjusted life years and total societal costs. The results indicate that the intervention is likely to be cost-effective, compared to attention only. The findings of the sensitivity analyses point in the same direction.

CONCLUSION

More research with larger samples is necessary to confirm the findings. The outcomes of this study may inform policy makers to decide which interventions will be included in policies. The guided Internet intervention may improve psychological care for people living with HIV and depressive symptoms, against low costs.

TRIAL REGISTRATION

Nederlands Trialregister NTR5407, September 11, 2015.

Internet-Delivered Cognitive Behavioural Therapy for Major Depression and Anxiety Disorders: A Health Technology Assessment

BACKGROUND

Major depression is defined as a period of depression lasting at least 2 weeks characterized by depressed mood, most of the day, nearly every day, and/or markedly diminished interest or pleasure in all, or almost all, activities. Anxiety disorders encompass a broad range of disorders in which people experience feelings of fear and excessive worry that interfere with normal day-to-day functioning.Cognitive behavioural therapy (CBT) is a form of evidence-based psychotherapy used to treat major depression and anxiety disorders. Internet-delivered CBT (iCBT) is structured, goal-oriented CBT delivered via the internet. It may be guided, in which the patient communicates with a regulated health care professional, or unguided, in which the patient is not supported by a regulated health care professional.

METHODS

We conducted a health technology assessment, which included an evaluation of clinical benefit, value for money, and patient preferences and values related to the use of iCBT for the treatment of mild to moderate major depression or anxiety disorders. We performed a systematic review of the clinical and economic literature and conducted a grey literature search. We reported Grading of Recommendations Assessment, Development, and Evaluation (GRADE) ratings if sufficient information was provided. When other quality assessment tools were used by the systematic review authors in the included studies, these were reported. We assessed the risk of bias within the included reviews. We also developed decision-analytic models to compare the costs and benefits of unguided iCBT, guided iCBT, face-to-face CBT, and usual care over 1 year using a sequential approach. We further explored the lifetime and short-term cost-effectiveness of stepped-care models, including iCBT, compared with usual care. We calculated incremental cost-effectiveness ratios (ICERs) from the perspective of the Ontario Ministry of Health and Long-Term Care and estimated the 5-year budget impact of publicly funding iCBT for mild to moderate major depression or anxiety disorders in Ontario. To contextualize the potential value of iCBT as a treatment option for major depression or anxiety disorders, we spoke with people with these conditions.

RESULTS

People who had undergone guided iCBT for mild to moderate major depression (standardized mean difference [SMD] = 0.83, 95% CI 0.59-1.07, GRADE moderate), generalized anxiety disorder (SMD = 0.84, 95% CI 0.45-1.23, GRADE low), panic disorder (small to very large effects, GRADE low), and social phobia (SMD = 0.85, 95% CI 0.66-1.05, GRADE moderate) showed a statistically significant improvement in symptoms compared with people on a waiting list. People who had undergone iCBT for panic disorder (SMD= 1.15, 95% CI: 0.94 to 1.37) and iCBT for social anxiety disorder (SMD=0.91, 95% CI: 0.74-1.07) showed a statistically significant improvement in symptoms compared with people on a waiting list. There was a statistically significant improvement in quality of life for people with generalized anxiety disorder who had undergone iCBT (SMD = 0.38, 95% CI 0.08-0.67) compared with people on a waiting list. The mean differences between people who had undergone iCBT compared with usual care at 3, 5, and 8 months were -4.3, -3.9, and -5.9, respectively. The negative mean difference at each follow-up showed an improvement in symptoms of depression for participants randomized to the iCBT group compared with usual care. People who had undergone guided iCBT showed no statistically significant improvement in symptoms of panic disorder compared with individual or group face-to-face CBT (d = 0.00, 95% CI -0.41 to 0.41, GRADE very low). Similarly, there was no statistically significant difference in symptoms of specific phobia in people who had undergone guided iCBT compared with brief therapist-led exposure (GRADE very low). There was a small statistically significant improvement in symptoms in favour of guided iCBT compared with group face-to-face CBT (d= 0.41, 95% CI 0.03-0.78, GRADE low) for social phobia. There was no statistically significant improvement in quality of life reported for people with panic disorder who had undergone iCBT compared with face-to-face CBT (SMD = -0.07, 95% CI -0.34 to 0.21).Guided iCBT was the optimal strategy in the reference case cost-utility analyses. For adults with mild to moderate major depression, guided iCBT was associated with increases in both quality-adjusted survival (0.04 quality-adjusted life-years [QALYs]) and cost ($1,257), yielding an ICER of $31,575 per QALY gained when compared with usual care. In adults with anxiety disorders, guided iCBT was also associated with increases in both quality-adjusted survival (0.03 QALYs) and cost ($1,395), yielding an ICER of $43,214 per QALY gained when compared with unguided iCBT. In this population, guided iCBT was associated with an ICER of $26,719 per QALY gained when compared with usual care. The probability of cost-effectiveness of guided iCBT for major depression and anxiety disorders, respectively, was 67% and 70% at willingness-to-pay of $100,000 per QALY gained. Guided iCBT delivered within stepped-care models appears to represent good value for money for the treatment of mild to moderate major depression and anxiety disorders.Assuming a 3% increase in access per year (from about 8,000 people in year 1 to about 32,000 people in year 5), the net budget impact of publicly funding guided iCBT for the treatment of mild to moderate major depression would range from about $10 million in year 1 to about $40 million in year 5. The corresponding net budget impact for the treatment of anxiety disorders would range from about $16 million in year 1 (about 13,000 people) to about $65 million in year 5 (about 52,000 people).People with depression or an anxiety disorder with whom we spoke reported that iCBT improves access for those who face challenges with face-to-face therapy because of costs, time, or the severity of their condition. They reported that iCBT provides better control over the pace, time, and location of therapy, as well as greater access to educational material. Some reported barriers to iCBT include the cost of therapy; the need for a computer and internet access, computer literacy, and the ability to understand complex written information. Language and disability barriers also exist. Reported limitations to iCBT include the ridigity of the program, the lack of face-to-face interactions with a therapist, technological difficulties, and the inability of an internet protocol to treat severe depression and some types of anxiety disorder.

CONCLUSIONS

Compared with waiting list, guided iCBT is effective and likely results in symptom improvement in mild to moderate major depression and social phobia. Guided iCBT may improve the symptoms of generalized anxiety disorder and panic disorder compared with waiting list. However, we are uncertain about the effectiveness of iCBT compared with individual or group face-to-face CBT. Guided iCBT represents good value for money and could be offered for the short-term treatment of adults with mild to moderate major depression or anxiety disorders. Most people with mild to moderate depression or anxiety disorders with whom we spoke felt that, despite some perceived limitations, iCBT provides greater control over the time, pace, and location of therapy. It also improves access for people who could not otherwise access therapy because of cost, time, or the nature of their health condition.

Preference for in-person psychotherapy versus digital psychotherapy options for depression: survey of adults in the U.S

Several barriers complicate access to psychotherapy for depression, including time commitment, location of services, and stigma. Digital treatment has the potential to address these barriers, yet long term use of digital psychotherapy is poor. This paper presents data from a mixed-methods, online survey to document concerns patients with depression face when given the choice of in-person psychotherapy and digital psychotherapy. Participants were 164 adults living in the United States who had previously used or considered psychotherapy for depression. Rural-dwelling and racial/ethnic minority (Native American, African American, and Spanish-speaking) respondents were purposively sampled. Participants were asked their preferences for and opinions about four treatment modalities: self-guided digital, peer-supported digital, expert-guided digital, or in-person psychotherapy. Less than half (44.5%) of participants preferred in-person psychotherapy, 25.6% preferred self-guided digital treatment, 19.7% preferred expert-guided digital treatment, and 8.5% peer-supported digital treatment. Principal themes extracted from qualitative analysis centered on the efficacy of digital treatment, access to digital treatment, concerns about peer-supported care, confidentiality and privacy concerns, preference for in-person treatment, skepticism about self-guided therapy, and the impact of social anxiety on the use of video-chat based care. Future development of digital psychotherapy will need to address concerns regarding efficacy, privacy, data security, and methods to enhance motivation to use these treatments.

Economic Evaluation of an Internet-Based Preventive Cognitive Therapy With Minimal Therapist Support for Recurrent Depression: Randomized Controlled Trial

Background

Major depressive disorder (MDD) is highly recurrent and has a significant disease burden. Although the effectiveness of internet-based interventions has been established for the treatment of acute MDD, little is known about their cost effectiveness, especially in recurrent MDD.

Objectives

Our aim was to evaluate the cost effectiveness and cost utility of an internet-based relapse prevention program (mobile cognitive therapy, M-CT).

Methods

The economic evaluation was performed alongside a single-blind parallel group randomized controlled trial. Participants were recruited via media, general practitioners, and mental health care institutions. In total, 288 remitted individuals with a history of recurrent depression were eligible, of whom 264 were randomly allocated to M-CT with minimal therapist support added to treatment as usual (TAU) or TAU alone. M-CT comprised 8 online lessons, and participants were advised to complete 1 lesson per week. The economic evaluation was performed from a societal perspective with a 24-month time horizon. The health outcomes were number of depression-free days according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) criteria assessed with the Structured Clinical Interview for DSM-IV axis I disorders by blinded interviewers after 3, 12, and 24 months. Quality-adjusted life years (QALYs) were self-assessed with the three level version of the EuroQol Five Dimensional Questionnaire (EQ-5D-3L). Costs were assessed with the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness (TiC-P). Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were displayed to assess the probability that M-CT is cost effective compared to TAU.

Results

Mean total costs over 24 months were €8298 (US $9415) for M-CT and €7296 (US $8278) for TAU. No statistically significant differences were found between M-CT and TAU regarding depression-free days and QALYs (P=.37 and P=.92, respectively). The incremental costs were €179 (US $203) per depression-free day and €230,816 (US $261,875) per QALY. The cost-effectiveness acceptability curves suggested that for depression-free days, high investments have to be made to reach an acceptable probability that M-CT is cost effective compared to TAU. Regarding QALYs, considerable investments have to be made but the probability that M-CT is cost effective compared to TAU does not rise above 40%.

Conclusions

The results suggest that adding M-CT to TAU is not effective and cost effective compared to TAU alone. Adherence rates were similar to other studies and therefore do not explain this finding. The participants scarcely booked additional therapist support, resulting in 17.3 minutes of mean total therapist support. More studies are needed to examine the cost effectiveness of internet-based interventions with respect to long-term outcomes and the role and optimal dosage of therapist support. Overall, more research is needed on scalable and cost-effective interventions that can reduce the burden of recurrent MDD.

Trial registration

Netherlands Trial Register NTR2503; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2503 (Archived by WebCite at http://www.webcitation.org/73aBn41r3)

Quantifying the economic impact of a digital self-care behavioral health platform on Missouri Medicaid expenditures

AIM

The primary objective of this study is to estimate the economic benefits relative to return on investment (ROI) of a state-wide initiative to integrate digital behavioral health (BH) self-care into the community BH system.

METHODS

The observational study reviewed claims data of 799 people who registered with the digital tool (myStrength) and 715 matched control study participants. The control group was formed via coarsened exact match with blocking variables, including presence on the claims file, volume of health care utilization, participation in a medical health home, BH diagnosis and volume of psychotherapy claims. The primary study analysis of cost differences for the BH self-care tool group versus the control group were calculated by cost setting and the ROI of the BH self-care tool was estimated. Cost settings assessed include inpatient, emergency services, general and psychiatric outpatient, and outpatient psychotherapy.

RESULTS

An incremental annual difference in difference reduction of $382 per user was observed over the 11 month study period in the self-care tool group. Sensitivity analysis indicated an ROI of between 142% and 695%.

CONCLUSIONS

Augmenting BH offerings to include digital BH self-care tools appears to generate positive ROI via reduced total cost of care.

Predicting Therapy Success and Costs for Personalized Treatment Recommendations Using Baseline Characteristics: Data-Driven Analysis

BACKGROUND

Different treatment alternatives exist for psychological disorders. Both clinical and cost effectiveness of treatment are crucial aspects for policy makers, therapists, and patients and thus play major roles for healthcare decision-making. At the start of an intervention, it is often not clear which specific individuals benefit most from a particular intervention alternative or how costs will be distributed on an individual patient level.

OBJECTIVE

This study aimed at predicting the individual outcome and costs for patients before the start of an internet-based intervention. Based on these predictions, individualized treatment recommendations can be provided. Thus, we expand the discussion of personalized treatment recommendation.

METHODS

Outcomes and costs were predicted based on baseline data of 350 patients from a two-arm randomized controlled trial that compared treatment as usual and blended therapy for depressive disorders. For this purpose, we evaluated various machine learning techniques, compared the predictive accuracy of these techniques, and revealed features that contributed most to the prediction performance. We then combined these predictions and utilized an incremental cost-effectiveness ratio in order to derive individual treatment recommendations before the start of treatment.

RESULTS

Predicting clinical outcomes and costs is a challenging task that comes with high uncertainty when only utilizing baseline information. However, we were able to generate predictions that were more accurate than a predefined reference measure in the shape of mean outcome and cost values. Questionnaires that include anxiety or depression items and questions regarding the mobility of individuals and their energy levels contributed to the prediction performance. We then described how patients can be individually allocated to the most appropriate treatment type. For an incremental cost-effectiveness threshold of 25,000 €/quality-adjusted life year, we demonstrated that our recommendations would have led to slightly worse outcomes (1.98%), but with decreased cost (5.42%).

CONCLUSIONS

Our results indicate that it was feasible to provide personalized treatment recommendations at baseline and thus allocate patients to the most beneficial treatment type. This could potentially lead to improved decision-making, better outcomes for individuals, and reduced health care costs.

Cost effectiveness of guided Internet-based interventions for depression in comparison with control conditions: An individual-participant data meta-analysis

BACKGROUND

There is limited evidence on the cost effectiveness of Internet-based treatments for depression. The aim was to evaluate the cost effectiveness of guided Internet-based interventions for depression compared to controls.

METHODS

Individual-participant data from five randomized controlled trials (RCT), including 1,426 participants, were combined. Cost-effectiveness analyses were conducted at 8 weeks, 6 months, and 12 months follow-up.

RESULTS

The guided Internet-based interventions were more costly than the controls, but not statistically significant (12 months mean difference = €406, 95% CI: - 611 to 1,444). The mean differences in clinical effects were not statistically significant (12 months mean difference = 1.75, 95% CI: - .09 to 3.60 in Center for Epidemiologic Studies Depression Scale [CES-D] score, .06, 95% CI: - .02 to .13 in response rate, and .00, 95% CI: - .03 to .03 in quality-adjusted life-years [QALYs]). Cost-effectiveness acceptability curves indicated that high investments are needed to reach an acceptable probability that the intervention is cost effective compared to control for CES-D and response to treatment (e.g., at 12-month follow-up the probability of being cost effective was .95 at a ceiling ratio of 2,000 €/point of improvement in CES-D score). For QALYs, the intervention's probability of being cost effective compared to control was low at the commonly accepted willingness-to-pay threshold (e.g., at 12-month follow-up the probability was .29 and. 31 at a ceiling ratio of 24,000 and 35,000 €/QALY, respectively).

CONCLUSIONS

Based on the present findings, guided Internet-based interventions for depression are not considered cost effective compared to controls. However, only a minority of RCTs investigating the clinical effectiveness of guided Internet-based interventions also assessed cost effectiveness and were included in this individual-participant data meta-analysis.

Assessing the costs and cost-effectiveness of ICare internet-based interventions (protocol)

BACKGROUND

Mental health problems are common and place a burden on the individual as well as on societal resources. Despite the existence of evidence-based treatments, access to treatment is often prevented or delayed due to insufficient health care resources. Effective internet-based self-help interventions have the potential to reduce the risk for mental health problems, to successfully bridge waiting time for face-to-face treatment and to address inequities in access. However, little is known about the cost-effectiveness of such interventions. This paper describes the study protocol for the economic evaluation of the studies that form the ICare programme of internet-based interventions for the prevention and treatment of a range of mental health problems.

METHODS

An overarching work package within the ICare programme was developed to assess the cost-effectiveness of the internet-based interventions alongside the clinical trials. There are two underlying tasks in the ICare economic evaluation. First, to develop schedules that generate equivalent and comparable information on use of services and supports across seven countries taking part in clinical trials of different interventions and second, to estimate unit costs for each service and support used. From these data the cost per person will be estimated by multiplying each participant's use of each service by the unit cost for that service. Additionally, productivity losses will be estimated. This individual level of cost data matches the level of outcome data used in the clinical trials. Following the analyses of service use and costs data, joint analysis of costs and outcomes will be undertaken to provide findings on the relative cost-effectiveness of the interventions, taking both a public sector and a societal perspective. These analyses use a well-established framework, the Production of Welfare approach, and standard methods and techniques underpinned by economic theory.

DISCUSSION/CONCLUSION

Existing research tends to support the effectiveness of internet-based interventions, but there is little information on their cost-effectiveness compared to 'treatment as usual'. The economic evaluation of ICare interventions will add considerably to this evidence base.