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Meeuwissen JAC, Feenstra TL, Smit F, Blankers M, Spijker J, Bockting CLH, van Balkom AJLM, Buskens E. The cost-utility of stepped-care algorithms according to depression guideline recommendations - Results of a state-transition model analysis. J Affect Disord 2019; 242:244-254. [PMID: 30216769 DOI: 10.1016/j.jad.2018.08.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/12/2018] [Accepted: 08/07/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Evidence-based clinical guidelines for major depressive disorder (MDD) recommend stepped-care strategies for sequencing evidence-based treatments conditional on treatment outcomes. This study aims to evaluate the cost-effectiveness of stepped care as recommended by the multidisciplinary clinical guideline vis-à-vis usual care in the Netherlands. METHODS Guideline-congruent care as described in stepped-care algorithms for either mild MDD or moderate and severe MDD was compared with usual care in a health-economic state-transition simulation model. Incremental costs per QALY gained were estimated over five years from a healthcare perspective. RESULTS For mild MDD, the cost-utility analysis showed a 67% likelihood of better health outcomes against lower costs, and 33% likelihood of better outcomes against higher costs, implying dominance of guideline-congruent stepped care. For moderate and severe MDD, the cost-utility analysis indicated a 67% likelihood of health gains at higher costs following the stepped-care approach and 33% likelihood of health gains at lower costs, with a mean ICER of about €3,200 per QALY gained. At a willingness to pay threshold of €20,000 per QALY, the stepped-care algorithms for both mild MDD and moderate or severe MDD is deemed cost-effective compared to usual care with a greater than 95% probability. LIMITATIONS The findings of our decision-analytic modelling are limited by the accuracy and availability of the underlying evidence. This hampers taking into account all individual differences relevant to optimise treatment to individual needs. CONCLUSIONS It is highly likely that guideline-congruent stepped care for MDD is cost-effective compared to usual care. Our findings support current guideline recommendations.
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Affiliation(s)
- Jolanda A C Meeuwissen
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands.
| | - Talitha L Feenstra
- Department of Epidemiology, Unit Health Technology Assessment, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands; Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Filip Smit
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands; Department of Epidemiology and Biostatistics and Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, The Netherlands
| | - Matthijs Blankers
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands; Department of Research, Arkin Mental Health Care, Amsterdam, The Netherlands; Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Program for Mood Disorders, Pro Persona Mental Health Care, Nijmegen, The Netherlands
| | - Jan Spijker
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands; Behavioral Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Claudi L H Bockting
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Erik Buskens
- Department of Epidemiology, Unit Health Technology Assessment, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
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Marrie RA, Miller A, Sormani MP, Thompson A, Waubant E, Trojano M, O'Connor P, Reingold S, Cohen JA. The challenge of comorbidity in clinical trials for multiple sclerosis. Neurology 2016; 86:1437-1445. [PMID: 26888986 PMCID: PMC4831041 DOI: 10.1212/wnl.0000000000002471] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/01/2015] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE We aimed to provide recommendations for addressing comorbidity in clinical trial design and conduct in multiple sclerosis (MS). METHODS We held an international workshop, informed by a systematic review of the incidence and prevalence of comorbidity in MS and an international survey about research priorities for studying comorbidity including their relation to clinical trials in MS. RESULTS We recommend establishing age- and sex-specific incidence estimates for comorbidities in the MS population, including those that commonly raise concern in clinical trials of immunomodulatory agents; shifting phase III clinical trials of new therapies from explanatory to more pragmatic trials; describing comorbidity status of the enrolled population in publications reporting clinical trials; evaluating treatment response, tolerability, and safety in clinical trials according to comorbidity status; and considering comorbidity status in the design of pharmacovigilance strategies. CONCLUSION Our recommendations will help address knowledge gaps regarding comorbidity that interfere with the ability to interpret safety in monitored trials and will enhance the generalizability of findings from clinical trials to "real world" settings where the MS population commonly has comorbid conditions.
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Affiliation(s)
- Ruth Ann Marrie
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH.
| | - Aaron Miller
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH
| | - Maria Pia Sormani
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH
| | - Alan Thompson
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH
| | - Emmanuelle Waubant
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH
| | - Maria Trojano
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH
| | - Paul O'Connor
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH
| | - Stephen Reingold
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH
| | - Jeffrey A Cohen
- From the Departments of Internal Medicine (R.A.M.) and Community Health Sciences (R.A.M.), University of Manitoba, Winnipeg, Canada; Icahn School of Medicine at Mount Sinai (A.M.), New York, NY; Biostatistic Unit (M.P.S.), Department of Health Sciences, University of Genova, Italy; Faculty of Brain Sciences (A.T.), University College London, UK; University of California San Francisco (E.W.); Department of Basic Medical Sciences, Neurosciences and Sense Organs (M.T.), University of Bari, Italy; St. Michael's Hospital (P.O.), Toronto, Canada; Scientific and Clinical Review Associates, LLC (S.R.), Salisbury, CT; and Mellen Center for MS Treatment and Research (J.A.C.), Cleveland Clinic, OH
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van den Hoek J, Roorda LD, Boshuizen HC, Tijhuis GJ, van den Bos GA, Dekker J. Physical and Mental Functioning in Patients with Established Rheumatoid Arthritis over an 11-year Followup Period: The Role of Specific Comorbidities. J Rheumatol 2016; 43:307-14. [DOI: 10.3899/jrheum.150536] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
Abstract
Objective.To investigate the longterm association of a wide range of comorbidities with physical and mental functioning in patients with rheumatoid arthritis (RA).Methods.Longitudinal data over a period of 11 years were collected from 882 patients with RA. Somatic comorbidity and comorbid depression were measured at baseline, with a questionnaire including 20 chronic diseases and with the Center for Epidemiologic Depression Scale, respectively. Physical functioning was measured at 5 timepoints with a disease-specific measure [Health Assessment Questionnaire (HAQ)] and a generic measure [physical scales of the Medical Outcomes Study Short Form-36 (SF-36)]. Mental functioning was measured with the mental scales of the SF-36. To determine the association of baseline-specific comorbidities with functioning over time, we performed longitudinal analyses.Results.At baseline, 72% percent of the patients were women, mean age ± SD was 59.3 ± 14.8 years, median RA disease duration was 5.0 years, and 68% had ≥ 1 comorbid condition. The effect of comorbid conditions was more apparent when physical functioning was measured with SF-36, a disease-generic measure, compared with the HAQ, a disease-specific measure. Circulatory conditions and depression were associated (p < 0.05) with worse physical functioning according to the HAQ. Respiratory conditions, musculoskeletal conditions, cancer, and depression were associated (p < 0.05) with worse physical functioning according to the SF-36. Respiratory conditions and depression were associated with worse mental functioning.Conclusion.Patients with specific comorbid conditions have an increased risk of low functioning in the long term. Targeted attention for these specific comorbid conditions by clinicians is recommended.
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Chen C, Si TM, Xiang YT, Ungvari GS, Wang CY, He YL, Kua EH, Fujii S, Sim K, Trivedi JK, Chung EK, Udomratn P, Chee KY, Sartorius N, Tan CH, Shinfuku N. Prevalence and prescription of antidepressants in depression with somatic comorbidity in Asia: the Research on East Asian Psychotropic Prescription Patterns study. Chin Med J (Engl) 2015; 128:853-8. [PMID: 25836602 PMCID: PMC4833998 DOI: 10.4103/0366-6999.154272] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Depression is often comorbid with chronic somatic diseases. Few previous studies have investigated the prevalence of somatic diseases in depression or the prescription pattern of antidepressants in comorbidly depressed patients in Asia. This study aimed to investigate the prevalence of somatic comorbidity (SC) in depression and compared the prescriptions of antidepressants in depressed patients with and without SC. Methods: A total of 2320 patients treated with antidepressants in 8 Asian countries were examined, and a diagnosis was based on the International Classification of Disease, 10th revision. We listed 17 common chronic somatic diseases. Patients’ socio-demographic and clinical characteristics and psychotropic drug prescriptions were recorded using a standardized protocol and data collection procedure. Results: Of the patients examined, 1240 were diagnosed with depression and 30% of them (n = 375) had SC. The most common comorbid condition was diabetes (23.7%). The patients with SC were more likely to seek help at a general hospital (74.7% vs. 47.2%), and had a higher incidence of symptoms involving sadness, disturbed sleep, and poor appetite. Noradrenergic and specific serotonergic antidepressant was prescribed more for patients with SC than for those without SC (30.4% vs. 22.9%). Conclusions: SC is common in depressed Asian patients. It is important to strengthen the recognition of depression, especially in general hospitals and when patients report some somatic discomfort. It is also a matter of urgency to establish evidence-based guidelines for the use of new antidepressants in depressed patients with SC.
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Affiliation(s)
| | - Tian-Mei Si
- Key Laboratory of Mental Health, Ministry of Mental Health and Peking University Institute of Mental Health, Beijing 100083, China
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Physical comorbidity and 12-week treatment outcomes in Korean patients with depressive disorders: the CRESCEND study. J Psychosom Res 2011; 71:311-8. [PMID: 21999974 DOI: 10.1016/j.jpsychores.2011.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/23/2011] [Accepted: 05/03/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Physical and depressive disorders frequently co-occur, but effects of physical health on depression treatment outcomes have received little research. This study aimed to compare treatment outcomes between people with depressive disorder with and without comorbid physical disorders. METHODS A Korean nationwide sample of 723 people with depressive disorder initiated on antidepressant treatment, and re-evaluated at 1, 2, 4, 8, and 12 weeks later. Assessment scales for evaluating depressive symptoms (HAMD), anxiety (HAMA), global severity (CGI-s), and functioning (SOFAS) were administered at baseline and every follow-up visit. Achievement of remission or response was defined only when these were maintained to the 12 weeks study endpoint or to the last follow-up examination, if earlier, with the date of the first observed remission point applied as the timing of remission. Logistic regression and Cox proportional hazards models were used. RESULTS Of the sample, 247 (34%) had at least one physical disorder. This was associated with lower socioeconomic status and more severe depressive symptoms at baseline, but was not associated with any treatment related characteristics including antidepressant type and regimen, concomitant medications, side effects, and duration of treatment period. After adjustment, patients with physical comorbidity responded more slowly and less often - particularly in domains of anxiety, global severity, and functioning (all p-values <.005). CONCLUSION More intensive assessment and integrated treatment approaches are needed to facilitate treatment responses for depressive disorders in people with physical comorbidity. Future comparative studies between conventional and integrated treatment approaches are indicated for depressive disorders with physical comorbidity.
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van der Feltz-Cornelis CM, Nuyen J, Stoop C, Chan J, Jacobson AM, Katon W, Snoek F, Sartorius N. Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis. Gen Hosp Psychiatry 2010; 32:380-95. [PMID: 20633742 DOI: 10.1016/j.genhosppsych.2010.03.011] [Citation(s) in RCA: 211] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Revised: 03/30/2010] [Accepted: 03/30/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND Comorbid depression in diabetes is highly prevalent, negatively impacting well-being and diabetes control. How depression in diabetes is best treated is unknown. OBJECTIVE This systematic review and meta-analysis aims to establish the effectiveness of existing anti-depressant therapies in diabetes. DATA SOURCES PubMed, Psycinfo, Embase and Cochrane library. Study eligibility criteria, participants, interventions: randomized controlled trials (RCTs) evaluating the outcome of treatment by psychotherapy, pharmacotherapy or collaborative care of depression in persons with Type 1 and Type 2 diabetes mellitus. STUDY APPRAISAL risk of bias assessment; data extraction. Synthesis methods: data synthesis, random model meta analysis and publication bias analysis. RESULTS Meta analysis of 14 RCTs with a total of 1724 patients show that treatment is effective in terms of reduction of depressive symptoms: -0.512; 95% CI -0.633 to -0.390. The combined effect of all interventions on clinical impact is moderate, -0.370; 95% CI -0.470 to -0.271; it is large for psychotherapeutic interventions that are often combined with diabetes self management: -0.581; 95% CI -0.770 to -0.391, n=310 and moderate for pharmacological treatment: -0.467; 95% CI -0.665 to -0.270, n=281. Delivery of collaborative care, which provided a stepped care intervention with a choice of starting with psychotherapy or pharmacotherapy, to a primary care population, yielded an effect size of -0.292; 95% CI -0.429 to -0.155, n=1133; indicating the effect size that can be attained on a population scale. Pharmacotherapy and collaborative care aimed at and succeeded in the reduction of depressive symptoms but, apart from sertraline, had no effect on glycemic control. LIMITATIONS amongst others, the number of RCTs is small. CONCLUSION The treatment of depression in people with diabetes is a necessary step, but improvement of the general medical condition including glycemic control is likely to require simultaneous attention to both conditions. Further research is needed.
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Affiliation(s)
- Christina M van der Feltz-Cornelis
- Research Program for Diagnosis and Treatment of Mental Disorder, Trimbos Instituut/Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
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