Online ISSN: 1099-176X Print
Copyright © 2009 ICMPE.
Cost-Effectiveness of a Psychoeducational Relapse Prevention Program for Depression in Primary Care
A. Dennis Stant,1 Elisabeth M. TenVergert,2 Herman Kluiter,3 Henk Jan Conradi,3 Annet Smit,4 Johan Ormel3
Epidemiology and Office for Medical Technology Assessment, University Medical Center Groningen, University of Groningen, the Netherlands.
* Correspondence to: A.D. Stant,
University Medical Center Groningen, Department of Epidemiology, P.O. Box
30.001, 9700 RB Groningen, the Netherlands.
Tel.: +31-50-361 4386
Fax: +31-50-361 4493
Source of Funding: Dutch Organization for Scientific Research (NWO), Medical Sciences Program and Chronic Diseases Program, Research Foundations of Health Insurance Company `HetGroeneLand', Regional Health Insurance Company (RZG), National Fund Mental Health (NFGV), and the University Medical Center Groningen, the Netherlands (indirect).
Background: Major depression is a prevalent mental disorder with a high risk of relapses and recurrences, which are associated with considerable burden for patients and high costs for society. Despite these negative consequences, only few studies have focused on interventions aimed at the prevention of recurrences in primary care patients with depression.
Aims of the Study: To assess the cost-effectiveness of a psychoeducational prevention program (PEP) aimed at improving the long-term outcome of depression in primary care.
Methods: Recruitment took place in the northern part of the Netherlands, patients were referred by general practitioners. In total 267 patients were included in the study and randomly assigned to usual care (UC) or UC with one of three forms of PEP; PEP alone, psychiatric consultation followed by PEP (psychiatrist-enhanced PEP), and cognitive behavioral therapy followed by PEP (CBT-enhanced PEP). Costs and health outcomes were registered at three month intervals during the 36 months follow-up of the study. Primary outcome measure was the proportion of depression-free time.
Results: Mean total costs during the 36 months of the study were 8200 in the UC group, 9816 in the PEP group, 9844 in the psychiatrist-enhanced PEP group, and 9254 in the CBT-enhanced PEP group. Costs of productivity losses, hospital admissions, contacts with regional institutions for mental healthcare, and medication use contributed substantially to the total costs in each group. Results of the primary outcome measure were less positive for PEP than for UC, but slightly better in the enhanced PEP groups. If decision-makers are willing to pay up to 300 for an additional proportion of depression-free time, UC is most likely to be the optimal intervention. For higher willingness to pay, CBT-enhanced PEP seems most efficient.
Discussion: The basic PEP intervention was not cost-effective in comparison with UC. The economic impact of productivity losses associated with depression, and the importance of including these costs in economic studies, was illustrated by the findings of this study. Due to the drop-out of patients during the 36 months follow-up period, economic analyses had to account for missing data, which may complicate the interpretation of the results. Although Quality-Adjusted Life Years (QALYs) could not be assessed for all the patients, the results of analyses focusing on QALYs supported the overall conclusion that PEP is not cost-effective.
Implications for Health Care Provision and Policies: Results indicated that PEP should not be implemented in the Dutch healthcare system. Furthermore, is seems highly unlikely that PEP could be cost-effective in other (comparable) European healthcare systems.
Implications for Further Research: The relatively positive economic results for CBT-enhanced PEP imply that UC enriched with CBT (but without PEP) might be cost-effective in preventing relapses in primary care patients with depression. The actual consequences of CBT for relapse prevention will have to be studied in further detail, both from a clinical and economic point of view.
Received 13 May 2008;
accepted 18 September 2009
Copyright © 2009 ICMPE