Cost effectiveness of psychological treatment for patients with chronic depression and anxiety

1. Cost effectiveness of psychological treatment for patients with chronic depression and anxiety Else Guthrie, James Moorey, Frank Margison, Helen Barker, Stephen Palmer, Graeme McGrath, Francis Creed, Barbara Tomenson Supported by a grant from the North West Regional Health Authority

2. Health economic issues • Cost-effectiveness measure in a common unit (e.g. years of life saved) • Cost-benefit conversion to a common unit (equivalents of currency) • Cost-utility addresses the usefulness in terms which can be expressed as social values (cost per added unit of a given utility such as a QALY) • Cost-minimisation If effects are equivalent, then minimise cost

3. Cost-offset studies • Small reduction of in-patient stay offsets cost of psychotherapy

4. Background • Health economic evaluation is becoming an increasingly important dimension of outcome in the assessment of treatment interventions. • Psychotherapy is perceived as an intensive and expensive treatment for mental illness. • Services are relatively under resourced.

5. Background • Most RCTs involving psychotherapy have focused on highly select patient groups with relatively acute problems. • Little work involving patients who have chronic psychological difficulties. • Yet, this group of patients are high consumers of health care, and suffer high levels of disability

6. Aims of the study • To determine whether brief psychotherapy compared with usual treatment, for patients with chronic psychological symptoms results in: • A) improved psychological health • B) improved health status and quality of life • C) reduced health care and associated costs

7. Entry Criteria • 18-65 years of age • Secondary psychiatric care for at least six months with no improvement • And did not have • Psychotic symptoms • Learning disability • Limited command of English • Dementia or brain damage

8. Trial Design Assess 1 Assess 2 Assess3 psychotherapy Treatment as usual Time 0 12 wks 6 months

9. Psychotherapy • 8 sessions (50 minutes) • Psychodynamic-interpersonal therapy • Developed in Manchester by Dr Robert Hobson Identify IP problems symptoms Elicit distress Interpersonal difficulties Modify IP problems Decrease distress

10. Previous Studies • Depression. • Shapiro D, Firth J. Prescriptive v Exploratory Psychotherapy: outcomes of the Sheffield Psychotherapy project. British Journal of Psychiatry, 1987; 151:790-799. • Shapiro DA, Barkham M, Rees A, Hardy GE, Reynolds S & Startup M. Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioural and psychodynamic –interpersonal psychotherapy. J Consult Clin Psychol 1994; 62:522-534. • Somatisation. • Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991; 100:450-457. • Hamilton J, Guthrie E, Creed F, Thompson D, Tomenson B. A randomized controlled trial of psychotherapy in chronic functional dyspepsia. Gastroenterology. In press 2000

11. Usual Treatment • Pharmacological treatment • Community support • Regular out-patient treatment • Behavioural interventions • Social work support

12. Measures • SCL-90-R measures global psychological distress Derogatis LR. SCL-90-R. Administration, scoring and procedures manual-II. Clinical Psychometric Research. 1992. • SCAN measures psychiatric disorder Schedules for Clinical Assessment in Neuropsychiatry. World Health Organisation. 1992. • SF-36 Ware JE & Sherbourne CD. The MOS 36-item short-form health survey (SF-36): 1. Conceptual framework and item selection. Med Care, 1993; 31:247-63. • Detailed measure of resource utilisation and cost

13. Costs • Direct treatment costs- health service data • Direct non-treatment costs- e.g. travel costs and additional patient expenditure • Indirect costs- e.g. time off work • Costs of psychotherapy included in the analysis (50 minutes per session plus 30 minutes for note recording plus supervision)

14. Data analysis • Continuous data compared using Student’s t test and ANCOVAR to control for baseline variation. • Health economic data had a highly skewed distribution- analysed by log transformation, geometric mean and the ratio of the mean differences are reported • Sensitivity analysis carried out to assess the robustness of the results

15. Results • 144 eligible patients • 110 entered the study • 34 refusals • Health economic assessments completed upon 93.6% patients at the end of treatment phase and 90% at six months follow-up

16. Demographics and illness duration • 69 females (62.7%) • Mean age 41.4 (SD=9.8) • Median length of current illness episode : 5 years (IQR 3-9years) • Median length of time patients had been in continuous contact with services : 3 years (IQR 2-6 years). • 68 (61.8) were incapable of work and were receiving state benefit.

17. Psychiatric Diagnoses • Axis I : Depression (75.5%) • Axis II: 43.6%

18. Psychotherapy group mean SEM n Treatment as usual group mean SEM n ANCOVAR P SCL-90-R GSI baseline T1 T2 2.01 0.10 54 1.82 0.11 52 1.76 0.13 42 2.03 0.11 55 1.92 0.11 49 2.05 0.07 49 0.25 0.034* SCL-90-R baseline Depression T1 Subscale T2 2.50 0.11 54 2.30 0.12 52 2.16 0.14 42 2.47 0.12 55 2.44 0.12 49 2.44 0.17 34 0.08 0.026* Psychological scores for psychotherapy vs treatment as usual group * p<0.05 ** p<0.01 ANCOVAR= analysis of covariance for the differences from baseline to end of treatment period (T1) and to six months follow-up assessment (T2), adjusting for any differences at baseline.

19. Total resource utilisation at baseline (for 3 months prior to study entry): psychotherapy group vs. treatment as usual

20. Resource utilisation for duration of trial period (T1) and six months follows-up (T2): psychotherapy group vs treatment as usual

21. Costs of treatment over baseline period (3 months) , duration of trial period (T1) (8 weeks) and six months follow-up period (T2): psychotherapy vs controls

22. Costs for psychotherapy and usual treatment group over the trial period P<0.05

23. Costs per week of treatment during the different phases of the study P<0.05

24. Health status • Patients in psychotherapy group reported significantly better social functioning at the at the six month follow-up compared with controls

25. Sensitivity analysis • 96.6% probability that the mean total direct treatment costs with psychotherapy would be lower (ie cost saving) than the base costs for the treatment as usual group.

26. Conclusions • One of the very few prospective randomised controlled trials of brief psychotherapy which has included a detailed health economic evaluation.

27. Conclusions • Brief psychotherapy for patients with enduring, disabling mental illness results in : • A) reduction in depression and anxiety • B) reduction in health care usage (both secondary and primary) in the six months post treatment. • C) improvement in psychological and social functioning produced at no extra cost overall

28. Clinical utility • Patients in this study had complex and enduring mental health problems • These patients often excluded from formal psychotherapy studies • Yet it is these patients that psychiatrists and GPs most want help with from psychological treatment services

29. Publications • GUTHRIE E, MOOREY J, BARKER H, MARGISON F, McGRATH G. Brief psychodynamic interpersonal therapy for patients with severe psychiatric illness which is unresponsive to treatment". British Journal of Psychotherapy. 1998, 15: 155-166. • GUTHRIE E, MOOREY J, MARGISON F, BARKER H, McGRATH G, PALMER S, TOMENSON B. • Cost-effectiveness of brief psychodynamic-interpersonal therapy in chronic utilisers of psychiatric services. • Archives of General Psychiatry, 1999, Vol 527, 519-526.