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Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: cost effectiveness |
Bower P, Byford S, Sibbald B, Ward E, King M, Lloyd M, Gabbay M |
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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 Non-directive counselling and cognitive-behaviour therapy for patients with depression or mixed anxiety and depression. Patients receiving psychological therapy were offered 6 - 12 sessions with a qualified therapist.
Economic study type Cost-effectiveness analysis.
Study population The study included patients with depression or mixed anxiety and depression. Exclusion criteria were: serious suicidal intent, psychological therapy in the past six months, currently taking antidepressant drugs, restricted mobility, organic brain syndromes, inability to complete questionnaires because of language difficulties, illiteracy or learning disability.
Setting 13 general practices in North London and 11 general practices in greater Manchester. The economic study was conducted in the United Kingdom.
Dates to which data relate Effectiveness data were collected between February 1996 and November 1997. Direct medical costs were based on GP records for the 12 months before and after referral to the study, while indirect patient costs related to 1997-1998. The price year was 1997-1998.
Source of effectiveness data The effectiveness data were derived from a single study.
Link between effectiveness and cost data Costing was undertaken prospectively on the main sample of 197 patients, randomly allocated to one of the 3 treatments.
Study sample 464 of the 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion. 197 patients were randomly assigned to treatment (usual GP care, 67 patients; cognitive behaviour therapy, 63; and non-directive counselling, 67), 137 chose their treatment and 130 were randomised only between the two psychological therapies. Power calculations related to the sample size indicated that 65 patients would be required in each group to detect a mean difference in outcome between the groups of 3.5 (SD 8) in Beck depression inventory score at 90% power and 5% level of significance.
Study design The study was a prospective, controlled trial with both randomised, and patient preference allocation arms. The randomisation element used numbered, sealed, opaque envelopes and was blocked and stratified on severity (high greater than or equal to 23) or low (14-22) on the Beck depression inventory. The duration of follow-up was 12 months. The follow-up rate on the main outcome measure (Beck depression inventory) was 89% at four months and 81% at 12 months.
Analysis of effectiveness The analysis was based on intention to treat. The main health outcomes considered in the analysis were Beck depression inventory scores, other psychiatric symptoms, social functioning and satisfaction with treatment measured at baseline and at 4 and 12 months. The 3 study groups were similar in terms of age, ethnic group and social class. 75% of participants were women.
Effectiveness results At four months, patients randomised to non-directive counselling or cognitive behaviour therapy improved more in terms of Beck depression inventory (mean (SD) scores of 12.9 (9.3) and 14.3 (10.8) respectively) than those randomised to usual GP care (18.3 (12.4)).
However, there was no significant difference between the two therapies for Beck inventory or other psychiatric symptoms, social functioning and satisfaction with treatment.
There were no significant differences between the two treatment groups at 12 months (Beck depression scores 11.8 (9.6), 11.4 (10.8) and 12.1 (10.3) for the 3 treatment groups.
Clinical conclusions Patients in all three arms of the trial improved on the primary outcome measure, but the patients in both psychological therapy groups made significantly greater clinical gains in the first four months after allocation. However, all groups had equivalent outcomes at 12 months.
Measure of benefits used in the economic analysis Since the effectiveness analysis showed no difference in effectiveness, the economic analysis was based on the difference in costs only (cost-minimisation). The study also examined Quality of Life as measured directly using the EuroQol instrument.
Direct costs Direct health service costs were considered namely contact with primary and secondary health services, psychotropic drugs and private health services. Sources were the databases of Personal Social Services Research Unit, the Chartered Institute of Public Finance and Accountancy, and the British National Formulary. 1997-98 prices were used. Quantities and costs were presented separately. Discounting was not performed due to the short duration of the study.
Statistical analysis of costs Mean costs were compared using standard t tests and analysis of variance methods and their validity was confirmed using bootstrapping.
Indirect Costs A societal perspective was used in the economic analysis and the following indirect costs were considered: cost of child care, travel and productivity losses. Child care and travel to secondary care were excluded from the analysis due to the small number of people reporting these. Only travel costs to primary care and to the psychological therapy session were considered (self-reported with unit costs being provided by the Automobile Association). The cost of productivity losses was based on self-reported, annual, monthly or weekly pay before tax. The price year was 1997-1998. Discounting was not relevant due to the short period considered.
Sensitivity analysis Univariate sensitivity analyses were performed.
Estimated benefits used in the economic analysis The reader is referred to the effectiveness results reported earlier. Due to their similarity the economic analysis was based on costs only. It was reported that there were no significant differences between the three groups in terms of Quality of Life.
Cost results There were no significant differences in direct costs, production losses, or societal costs between the three treatments at either 4 or 12 months. Mean one-year costs were as follows.
Societal costs: usual GP care, 1,202.8; cognitive-behaviour therapy, 954.9; and non-directive counselling, 1,409.6.
Direct costs: usual GP care, 419.9; cognitive-behaviour therapy, 470.5; and non-directive counselling, 532.3.
Indirect costs (the authors considered only production losses as indirect costs): usual GP care, 782.9; cognitive-behaviour therapy, 484.4; and non-directive counselling, 877.3.
Synthesis of costs and benefits Not performed due to the similarity of effectiveness results.
Authors' conclusions Within the constraints of available power, the data suggest that both brief psychological therapies may be significantly more cost-effective than usual care in the short term, as benefits were gained with no significant differences in costs. However, there were no significant differences between treatments in either outcomes or costs at 12 months.
CRD COMMENTARY - Selection of comparators The reason for the choice of the comparator, usual care, was clear. You, as a database user, should consider if the same applies to your own setting.
Validity of estimate of measure of benefit Given the randomised design of the study, the validity of the effectiveness results seems to be assured, with limitations determined by the low power of the study. As the effectiveness analysis showed similarity between the 3 treatment groups, the authors, appropriately, carried out a cost-minimisation analysis.
Validity of estimate of costs Sufficient details were given on cost estimation. Quantities and costs were presented separately and a societal perspective was used for cost analysis. Costs were not discounted due to the short duration of the study. The authors acknowledge the fact that the findings of the study must be considered as being preliminary due to high variability in the cost data and the low power of cost calculations.
Other issues The authors made appropriate comparisons with, and found similar findings in, other studies. Costs may not be generalisable to other countries.
Implications of the study Given the equivalence of the results, commissioners of services are in a position to decide on services based on factors other than outcomes and costs, such as staff and patient preferences or staff availability. There is no evidence that psychological therapies are more cost-effective, in the long term, than usual care.
Source of funding Funded by a grant from the NHS Executive Health Technology Assessment Programme.
Bibliographic details Bower P, Byford S, Sibbald B, Ward E, King M, Lloyd M, Gabbay M. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: cost effectiveness. BMJ 2000; 321: 1389-1392 Indexing Status Subject indexing assigned by NLM MeSH Adult; Anxiety Disorders /economics /therapy; Cognitive Therapy /economics /methods; Cost-Benefit Analysis; Depressive Disorder /economics /therapy; England; Family Practice /economics; Female; Humans; Male; Sensitivity and Specificity; Treatment Outcome AccessionNumber 22000008348 Date bibliographic record published 30/06/2001 Date abstract record published 30/06/2001 |
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