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Collaborative care models for the treatment of depression |
Katon W |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Collaborative care models for the treatment of depression.
Economic study type Cost-effectiveness analysis.
Study population Patients in a large Group Health Co-operative primary care clinic who had definite or probable major depression and who were beginning treatment with antidepressants.
Setting Primary care. The study was carried out in the USA.
Dates to which data relate Effectiveness and resource use data were collected from two trials published in 1995 and 1996. Cost data were collected from a 1998 source. The price year was not reported.
Source of effectiveness data Effectiveness data were derived from a single study.
Link between effectiveness and cost data The costing was undertaken on the same patient sample as that used in the effectiveness analysis. The costing was carried out after the results of the effectiveness analysis were known.
Study sample For the psychiatry-primary care model, 217 patients were randomised to the control or intervention arm. For the psychiatrist/psychologist-primary care model, 153 patients were randomised to the control or intervention arm. No power calculations were reported.
Study design Effectiveness estimates were derived from two linked randomised controlled trials, carried out at a single centre. For the psychiatry-primary care model, patients were followed up at 1, 4, and 7 months.
Analysis of effectiveness The analysis of the clinical study was based on intention to treat. The primary health outcomes studied included dosage, satisfaction with care, helpfulness of antidepressants, and depression outcomes. The authors did not state whether groups were comparable in terms of demographic characteristics.
Effectiveness results For the psychiatry-primary care model and for patients suffering from major depression, the dosage was adequate in 75.5% of patients in the intervention group and 50% of patients in the control group, (p<0.01). 93% of patients in the intervention group and 75% of patients in the control group (p<0.03) were satisfied with care. 88.1% of patients in the intervention group and 63.3% of patients in the control group (p<0.01) found antidepressants helpful. At 4 months, the intervention led to a 50% reduction in severity in 74.4% of patients in the intervention group and 43.8% of patients in the control group, (p<0.01). For the psychiatry-primary care model and for patients suffering from minor depression, the dosage was adequate in 79.7% of patients in the intervention group and 40.3% of patients in the control group, (p<0.001). 81.8% of patients in the intervention group and 61.4% of patients in the control group (p<0.01) found antidepressants helpful. The results of the psychiatrist/psychologist-primary care model showed similar outcomes, with major depression being more affected by the intervention that the minor depressives. 65% of primary care physicians indicated that the intervention had greatly increased their satisfaction and skills in treating depression.
Clinical conclusions Collaborative management of major depression improves adherence, satisfaction, and depressive outcomes. Among patients with minor depression, collaborative care improved medication adherence and one measure of satisfaction.
Modelling No modelling was undertaken.
Measure of benefits used in the economic analysis The proportion of patients successfully treated (50% or greater reduction in severity) was used as the measure of benefits.
Direct costs Costs were not discounted given the short time frame of the study (less than 1 year). Quantities and costs were reported separately. Direct costs included the costs for primary care visits, antidepressant medication, and visits to a psychologist or psychiatrist. The quantity/cost boundary adopted was that of the health service. The estimation of quantities and costs was based on actual data. Cost data were derived from a study published in 1998. The price year was not reported.
Statistical analysis of costs A statistical analysis of costs was not reported.
Indirect Costs Indirect costs were not included.
Sensitivity analysis Sensitivity analysis was not reported.
Estimated benefits used in the economic analysis For the psychiatry-primary care model, the proportion of patients successfully treated was 0.744 in the intervention group (n=41) and 0.438 in the control group (n=33). These results related to patients with major depression only, as differences were not determined for minor depressions.
Cost results For the psychiatry-primary care model, the cost per patient treated was $1,336 in the intervention group and $850 in the control group. Again, these results refer only to major depressions.
Synthesis of costs and benefits The cost-effectiveness was $1,797 in the intervention group and $1,941 in the control group. The incremental cost-effectiveness was $1,591 per patient.
Authors' conclusions Although cost offsets through the interventions were not demonstrated, the cost of successfully treating one patient with major depression was lower with the interventions, and the incremental costs of collaborative intervention were substantially lower than the usual primary care costs.
CRD COMMENTARY - Selection of comparators A justification was given for the comparator used, namely currently available treatment options. You, as a user of the database, should decide if these health technologies are relevant to your setting.
Validity of estimate of measure of benefit The analysis was based on two randomised-controlled trials, which was appropriate for the study question. The study sample was representative of the study population. The authors did not state, however, whether the groups were comparable in terms of demographic characteristics. The analysis of effectiveness was handled credibly. The estimation of benefits was obtained directly from the effectiveness analysis.
Validity of estimate of costs All categories of costs relevant to the perspective adopted were included in the analysis. Costs and quantities were not, however, reported separately and no sensitivity analysis was conducted on costs or quantities. Costs were used to proxy prices. The price year was not reported. These limitations tend to restrict the generalisability of the results to other settings.
Other issues The authors did not report appropriate comparisons of their findings with those from other studies. The issue of generalisability to other settings was not addressed. The authors do not, however, appear to have presented their results selectively. The study enrolled patients suffering from depression and this was reflected in the authors' conclusions.
Implications of the study Because of the expense associated with the mental health intervention, integration may be more problematic in small practices, and other models of care may need to be developed.
Bibliographic details Katon W. Collaborative care models for the treatment of depression. American Journal of Managed Care 1999; 5(13 Supplement S): S794-S810 Indexing Status Subject indexing assigned by NLM MeSH Continuity of Patient Care /organization & Depression /therapy; Health Care Costs; Humans; Models, Organizational; Patient Satisfaction; Primary Health Care /economics /organization & Psychiatry /economics /organization & United States; administration; administration; administration AccessionNumber 21999001868 Date bibliographic record published 31/01/2001 Date abstract record published 31/01/2001 |
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