The role of economic evaluation in mental health care

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.

The PROCEM study protocol: Added value of preoperative contrast-enhanced mammography in staging of malignant breast lesions - a prospective randomized multicenter study

BACKGROUND

Correct preoperative estimation of the malignant extent is crucial for optimal planning of breast cancer surgery. The sensitivity of mammography is lower in dense breasts, and additional imaging techniques are sometimes warranted. Contrast-enhanced mammography (CEM) has shown similar sensitivity and in some cases better specificity, than magnetic resonance imaging (MRI) in small, observational studies. CEM may be more cost-effective than MRI, and may provide better identification of the tumor extent, however, no randomized trials have been performed to date to investigate the added value of CEM. In a feasibility study, we found that the treatment was changed in 10/47 (21%) cases after additional CEM. The purpose of the present study is to evaluate the added value of CEM in preoperative staging of breast cancer in a randomized study.

METHOD

This prospective randomized study will include 440 patients with strongly suspected or established diagnosis of breast malignancy, based on assessment with mammography, ultrasound and core biopsy/cytology, and for whom primary surgery is planned. Patients will be randomized 1:1 using a web-based randomization tool to additional investigation with CEM or no further imaging. The CEM findings will be taken into consideration, which may lead to changes in primary treatment, which is the primary endpoint of this study. Secondary endpoints include rate of reoperation and number of avoidable mastectomies, as well as a cost-benefit analysis of additional CEM. Patient-reported health-related quality of life will be investigated at 1 year with the validated Breast-Q™ questionnaire. The rate of local recurrence or new cancer ipsi- or contralaterally within 5 years will be assessed from medical records and pathology reports.

DISCUSSION

The aim of this trial is to explore the added value of CEM in preoperative staging of breast cancer. The results obtained from this study will contribute to our knowledge on CEM as an additional imaging method to standard investigation with digital mammography and ultrasound. The findings may also provide additional information on which patient groups would benefit from CEM, and on the economic aspects of CEM in standard preoperative practice.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov , registration no: NCT04437602 , date of registration: June 18, 2020.

Quality of life assessment in paediatric cochlear implant recipients in South India: Parental assessment and correlation with rehabilitation scores using a bilingual quality of life assessment questionnaire

Objectives: To assess the quality of life (QoL) of prelingually deaf paediatric population after Cochlear implantation (CI), using a bilingual questionnaire and to correlate with rehabilitation scores; to validate the questionnaire and recommend its use in future studies.Methods: This was a questionnaire based cross-sectional study. Parents of 151 paediatric prelingual CI recipients filled the questionnaire using a 5-point rating scale, with a score of 1-5. These scores were correlated with the CAP and SIR scores.Results and discussion: There was a positive correlation of QoL score with rehabilitation outcomes (r = 0.4638 and P ≤ 0.00001 for CAP; r = 0.3563 and P ≤ 0.00001 for SIR scores). The maximum scores (≥4.0) were given by parents for integration into educational system (4.86), response to environmental sounds (4.12) and overall parental satisfaction about child's performance (4.09). Minimum scores were given for ability to speak in sentences (2.9) and response to verbal sounds at a distance (3.23).Conclusion: The QoL of these children as assessed by the institutional questionnaire have correlated with the rehabilitation outcomes. These QoL results have a positive impact in counselling for early CI as well as for rehabilitation.

Direct and indirect cost of attempted suicide in a general hospital: cost-of-illness study

CONTEXT AND OBJECTIVE

Knowledge of socioeconomic impact of attempted suicide may sensitize managers regarding prevention strategies. There are no published data on this in Brazil. The aim here was to describe the direct and indirect costs of care of hospitalized cases of attempted suicide and compare these with the costs of acute coronary syndrome cases.

DESIGN AND SETTING

Cost-of-illness study at a public university hospital in Brazil.

METHOD

The costs of care of 17 patients hospitalized due to attempted suicide were compared with those of 17 acute coronary syndrome cases at the same hospital, over the same period. The direct costs were the summation of the hospital and out-of-hospital costs resulting from the event, determined from the medical records. The indirect costs were estimated through the human capital lost. The Mann-Whitney test and analysis of covariance (ANCOVA) with transformation adjusted for age were used for comparisons.

RESULTS

The average costs per episode of attempted suicide were: direct cost, US$ 6168.65; indirect cost, US$ 688.08; and total cost, US$ 7163.75. Comparative analysis showed a difference between the indirect costs to family members, with significantly higher costs in the attempted suicide group (P = 0.0022).

CONCLUSION

The cost of care relating to attempted suicide is high and the indirect cost to family members reinforces the idea that suicidal behavior not only affects the individual but also his social environment.

Factors explaining priority setting at community mental health centres: a quantitative analysis of referral assessments

Background

Clinicians at Norwegian community mental health centres assess referrals from general practitioners and classify them into three priority groups (high priority, low priority, and refusal) according to need where need is defined by three prioritization criteria (severity, effect, and cost-effectiveness). In this study, we seek to operationalize the three criteria and analyze to what extent they have an effect on clinical-level priority setting after controlling for clinician characteristics and organisational factors.

Methods

Twenty anonymous referrals were rated by 42 admission team members employed at 14 community mental health centres in the South-East Health Region of Norway. Intra-class correlation coefficients were calculated and logistic regressions were performed.

Results

Variation in clinicians’ assessments of the three criteria was highest for effect and cost-effectiveness. An ordered logistic regression model showed that all three criteria for prioritization, three clinician characteristics (education, being a manager or not, and “guideline awareness”), and the centres themselves (fixed effects), explained priority decisions. The relative importance of the explanatory factors, however, depended on the priority decision studied. For the classification of all admitted patients into high- and low-priority groups, all clinician characteristics became insignificant. For the classification of patients, into those admitted and non-admitted, one criterion (effect) and “being a manager or not” became insignificant, while profession (“being a psychiatrist”) became significant.

Conclusions

Our findings suggest that variation in priority decisions can be reduced by: (i) reducing the disagreement in clinicians’ assessments of cost-effectiveness and effect, and (ii) restricting priority decisions to clinicians with a similar background (education, being a manager or not, and “guideline awareness”).

The pharmacoeconomics of managing acute agitation in the emergency department: what do we know and how do we approach it?

The emergency department (ED) is commonly the first point of care for patients with acute behavioral issues from the community. Routinely, clinical management involves the use of benzodiazepine and/or antipsychotic drugs, when initial de-escalation strategies fail. There is currently scant literature available to inform the clinical management and resource utilization of acute agitation in the ED. This article discusses the approach to pharmacoeconomic studies of acute agitation management in the ED. It explores the conduct of such evaluations and highlights the cost and data sources required. The current difficulties experienced in conducting such evaluations are also discussed. Pharmacoeconomic studies related to the management of acute agitation in ED can be challenging. Robust clinical trials incorporating prospectively designed pharmacoeconomic studies will invariably contribute toward a better understanding of this therapeutic area and optimize the use of scarce resources.

Cost-effectiveness analysis for antidepressants and cognitive behavioral therapy for major depression in Thailand

OBJECTIVE

To determine the cost-effectiveness of fluoxetine and cognitive-behavioral therapy (CBT) for major depression in Thailand.

METHODS

A microsimulation model was developed to describe the variation in course of disease between individuals. Model inputs included Thai data on disease parameters and costs while impact measures were derived from a systematic review and meta-analysis of the international literature. Fluoxetine as the cheapest antidepressant drug in Thailand was analyzed for treatment of episodes plus a 6-month continuation phase and for maintenance treatment over 5 years of follow-up. CBT was analyzed for episodic treatment and for 5-year maintenance treatment. Results are presented as cost (Thai bahts) per disability-adjusted life-year (DALY) averted, compared with a "do-nothing" scenario.

RESULTS

The cost-effectiveness ratios of all interventions were below 1 time Thailand's gross domestic product of 110,000 bahts per capita. The uncertainty ranges around the cost-effectiveness ratios overlap: maintenance treatment with CBT 11,000 bahts per DALY (8,000-14,000); episodic treatment with CBT 23,000 bahts per DALY (10,000-36,000); episodic plus continuation drug treatment 33,000 bahts per DALY (26,000-44,000); maintenance drug treatment 38,000 bahts per DALY (30,000-48,000); and episodic drug treatment 42,000 bahts per DALY (32,000-57,000).

CONCLUSIONS

CBT and generic fluoxetine are cost-effective treatment options for both episodic and maintenance treatment of major depression in Thailand. Maintenance treatment has the greatest potential of health gain.

Cost-effectiveness of an early assessment service for young people with early psychosis in Hong Kong

OBJECTIVE

The Early Assessment Service for Young People with Early Psychosis (EASY) was developed in Hong Kong in 2001 to provide a comprehensive and integrated approach for early detection and intervention for young people suffering from first episode psychosis. The present study examined the cost-effectiveness of the service over a period of 24 months compared to standard care.

METHOD

This is a historical control study. Sixty-five patients who presented to the EASY service in 2001 with first episode psychosis were individually matched (on age, sex and diagnosis) with 65 patients who received standard psychiatric care in a precursor service (pre-EASY) between 1999 and 2000. A retrospective cost-effectiveness analysis was conducted over a period of 24 months. The overall average cost of service utilization per patient and the effects on hospitalization rate were compared using bootstrapping analysis. Cost per point improvement in Positive and Negative Syndrome Scale (PANSS) was also computed with sensitivity analysis. Only direct costs were analysed in the current study.

RESULTS

There was no significant difference in service utilization between the EASY and pre-EASY standard care groups. The cost-effectiveness acceptability curve, which was used to explore uncertainty in estimates of cost and effects, suggested that there was a probability of at least 94% that the EASY model was more cost-effective than the pre-EASY service in reducing psychiatric inpatient admissions. EASY patients also showed superior results in average cost per unit improvement in PANSS.

CONCLUSIONS

EASY is likely to be more cost-effective in improving outcomes, particularly in reducing hospitalization and improving clinical symptoms among young people with first episode psychosis. This study provides a perspective from the east Asian region, and supports further development of similar services, particularly in the local setting. However, further studies with a longer follow up period and larger sample size are required to verify these findings.

Many faces of the dual-role dilemma in psychiatric ethics

OBJECTIVE

To identify the various potential manifestations of the dual-role dilemma in the psychiatric ethics literature.

METHOD

The terms 'dual role', 'dual agency', 'overlapping roles', and 'double agency' were searched on the electronic databases PubMed, Medline, Embase and PsychInfo. Classic papers in the field of psychiatric ethics and their references were manually searched. Papers were selected for relevance to the topic of the dual-role dilemma in relation to psychiatry.

RESULTS

The dual-role dilemma is most explicitly addressed in the literature on forensic psychiatry and military psychiatry. Review of the ethics literature in other fields of psychiatry indicates many instances of the dilemma of psychiatrists facing conflicting obligations akin to the dual-role problem identified in the literature on forensic psychiatry. Many of these dilemmas are characterized by the presence of a powerful third party to whom the psychiatrist has some perceived obligations.

CONCLUSIONS

In psychiatric ethics, the dual-role dilemma refers to the tension between psychiatrists' obligations of beneficence towards their patients, and conflicting obligations to the community, third parties, other health-care workers, or the pursuit of knowledge in the field. These conflicting obligations transcend a conflict of interest in that the expectations of the psychiatrist, other than the patient's best interests, are so compelling. This tension illustrates how the discourse in psychiatric ethics is embedded in the social and cultural context of the situations encountered. It appears that as society changes in its approach to the value of liberal autonomy and the 'collective good', psychiatrists may also need to change.

Overview of psychiatric ethics V: utilitarianism and the ethics of duty

OBJECTIVE

The aim of this paper is to describe the ethical theories of utilitarianism and the ethics of duty (Kant's ethics) and to evaluate their value as theoretical bases of psychiatric ethics.

CONCLUSIONS

Utilitarianism is a well-established moral philosophy and has significant instrumental value in dealing with common ethical problems faced by psychiatrists. Despite its capacity to generate solutions to ethical problems, utilitarianism requires a process of what Rawls described as 'reflective equilibrium' to avoid morally repugnant choices, based on utility. The criticisms of utilitarianism, such as the problems of quantifying utility and the responsibility for consequences, are very relevant for psychiatry. Singer's model of utilitarian thinking is particularly problematic for our profession. Kant's ethics provides the pretext for duty bound codes of ethics for psychiatrists, but suffers from problems of flawed claims to the universalizability prescribed by Kant's 'categorical imperative'. Kant's valorization of reason as the core of the autonomy of persons is a valuable insight in understanding psychiatrists' ethical obligations to their patients.

Patterns of treatment response in chronic posttraumatic stress disorder: an application of latent growth mixture modeling

This study attempts to differentiate groups of individuals who exhibit different patterns of recovery following treatment for chronic posttraumatic stress disorder (PTSD) and describes these groups in terms of relevant characteristics at program intake. A sample of 2,219 Vietnam veterans who had completed a 12-week treatment program was followed up at 6, 12, and 24 months post admission using self-report measures. With change in PTSD symptoms over time as the focus, latent growth mixture modeling was used to assign individual veterans to subgroups. A three-group solution provided the best account of the data. Two groups showed moderate and consistent improvement over time although the larger group (n = 1,380) began treatment with more PTSD symptoms and improved more quickly over time. The smallest group (n = 87) showed a substantially different trajectory, with almost no net change in symptom levels over the 24-month period. The groups also varied significantly in terms of their characteristics, with symptom severity and improvements over time reflecting greater comorbidity and younger age. The results have both research and clinical implications.

Measurement of indirect costs for people with vision impairment

From a societal perspective, chronic eye diseases can affect not only the person who has vision impairment but also the economics of that society. To obtain comprehensive medical and non-medical expenditures for people with impaired vision, direct and indirect costs should be collected. Indirect costs are usually not included in cost evaluation in health economics due to the difficulty of the data collection and analysis. Questionnaires and cost diaries have been developed in this study to estimate total resource use, expenses, and lost production from the participants or their caregivers due to the participants' vision loss. Pilot testing was conducted to verify the format, clarity of instructions, relevance of content and completeness of the questionnaires and diary. Modifications were then made to the format from feedback from the participants. Diaries using large print, audio and Braille facilitate data collection for people with impaired vision.

Allocation of resources and psychosis

OBJECTIVE

This commentary reviews current expenditure on psychosis in Australia, identifies discretionary expenditure that could be used more efficiently, discusses the factors influencing resource allocation and intervention selection decisions, and suggests priorities for change.

METHOD

Cost-of-illness findings from the Low Prevalence Disorders Study (LPDS), and related service use and psychosocial data, are used to highlight patterns of expenditure on psychosis and potential resource allocation issues. Arguments are also presented suggesting that mental health resource allocation in Australia should be informed primarily by treatment efficiency, equity and humanitarian considerations, not differences in the global burden of disease. However, our evidence-base about the effectiveness and costs associated with individual treatments, programmes, and organizational structures is also shown to be limited.

CONCLUSIONS

The patterns of service use and expenditure on psychosis suggest certain imbalances, including an over-reliance on hospitalization, low levels of supported community accommodation, and inadequate provision of evidence-based psychosocial treatments, rehabilitation and supported employment programmes. We need to identify and develop efficient interventions and programmes, re-orientate our services to better utilize those interventions, increase community awareness, improve monitoring of outcomes and costs, and undertake timely evaluations at multiple levels, from the individual to the societal perspective.

Measuring disability-specific patient benefit in cochlear implant programs: developing a short form of the Glasgow Health Status Inventory, the Hearing Participation Scale

As healthcare resources are limited, evidence of program effectiveness is necessary. To demonstrate this, measurement should be conducted at the specific illness level, the generic health status level, and the utility level. Instruments need to be parsimonious to avoid cognitive overload, response burden, or participation refusal. Critical analysis of the Glasgow Hearing Status Inventory (GHSI) suggested that several items were redundant and the instrument could be shortened. We administered the GHSI and Assessment of Quality of Life (AQoL) instruments to 148 deafened adults with cochlear implants (CIs) and to 54 without CIs, as part of a cross-sectional study. We used standard psychometric procedures to examine the GHSI's structure, resulting in the removal of half of the items. The short version of the GHSI we labeled the Hearing Participation Scale (HPS), to avoid confusion with the GHSI. The HPS is an 11-item instrument measuring self-esteem, social handicap, and hearing handicap. Factor analysis suggested that each subscale was unidimensional. All items loaded on the principal component. Correlation with the GHSI was 0.95, suggesting that the two instruments could be used interchangeably. Both the HPS and the GHSI pro-vided evidence of monotonicity when used to predict AQoL scores. They were equally sensitive at differentiating between implantees and non-implantees. Although these findings need to be confirmed, the HPS is ready to be used in studies of interventions for deafness. At a time when evaluators are being asked for evidence of program effect, the parsimonious HPS achieves similar results to the GHS but requires half the items.

A five year follow-up study of the use of clozapine in community practice

OBJECTIVE

To present information about the value of clozapine in treatment-resistant schizophrenia. Data is reported on the use of clozapine in an entire cohort of (42) patients in a community, the Australian Capital Territory. It extends a 3-year study of clinical and financial outcomes to 5 years.

METHOD

Experiences during the 2 years before clozapine was prescribed and those of the 5 years following prescription were compared by a records review, including hospital and hostel bed use and estimated treatment costs. Changes in dose levels, living circumstances and employment status were assessed, and treating psychiatrists reported on side-effects and their impression of clinical change since clozapine was prescribed.

RESULTS

Ten subjects were excluded. The remaining cohort (32 subjects) demonstrated continuing clinical improvement and cost savings during follow-up. Those (22) remaining on clozapine after the five year period showed continuing clinical improvement, reduced hospital admissions and hospital bed usage and significantly large cost savings, and were moderately to markedly improved after 3 years. Only one patient (of 22) showed a slight deterioration in the next two years while 14 showed further improvement. After 5 years, the clinical status of four of the 10 subjects who discontinued clozapine was unchanged or deteriorated compared with their preclozapine status. There were no suicides.

CONCLUSION

The findings of continuing clinical improvement and decreased costs after long-term (5 years) use of clozapine supports the selective use of clozapine in community practice.

Mental disorders and burden of disease: how was disability estimated and is it valid?

OBJECTIVE

The Global Burden of Disease study found mental disorders to be the world's leading cause of disability. Few studies have examined the validity of the novel approach used to estimate disability, the person trade-off preference method. This paper describes, and examines the validity of, the burden of disease person trade-off protocol.

METHOD

The person trade-off provides preferences for health states (how good or bad you think it is in relation to perfect health). General practitioners (n = 20) with training in mental health provided preferences for 19 mental disorders using the person trade-off method. Descriptions for the mental disorders were derived from the average symptom severity and disability observed in the Australian National Survey of Mental Health and Wellbeing. Validity was investigated by comparison with two other methods (rating scale and rank order).

RESULTS

The general practitioners found the person trade-off complex and affronting. Only a moderate concordance was observed with two validity comparisons; however, validity was significantly increased following the opportunity for group discussion among the clinicians. The disability weights were higher than those used in the global study, a possible consequence of differences in disorder descriptions.

CONCLUSIONS

The present study is limited by small subject numbers and by using only one type of key informant (clinicians). While this study provided some evidence for the validity of the person trade-off, it also echoes concerns from recent commentaries about the feasibility of this method. These concerns are particularly relevant for mental disorder burden, which relies heavily on the magnitude of the disability weights. Further work is required to ensure that disability burden is validly estimated, and thus can appropriately be used to inform mental health policy.