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Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation |
Green JM, Wood AJ, Kerfoot MJ, Trainor G, Roberts C, Rothwell J, Woodham A, Ayodeji E, Barrett B, Byford S, Harrington R |
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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. CRD summary This study examined the costs and effectiveness of group therapy for young people aged 12 to 17 years, who had at least two episodes of self-harm in the previous year. The authors concluded that the group therapy was not a cost-effective addition to routine care, at any likely willingness-to-pay threshold. The methods, analyses, and results were mostly clear and comprehensive. The conclusions reached by the authors appear to be appropriate. Type of economic evaluation Cost-effectiveness analysis Study objective The aim was to examine the costs and effectiveness of group therapy for young people aged 12 to 17 years, who had at least two episodes of self-harm in the previous 12 months. Self-harm included intentional drug overdose and self-inflicted injuries, such as cutting, scratching, burning, or strangulation. Interventions Group therapy was an addition to routine care and was compared with routine care alone. Group therapy was a combination of cognitive-behavioural therapy, dialectal behavioural therapy, and group psychotherapy. It was delivered by therapists who had a minimum of three years experience after qualification. Routine care was provided by the local child and adolescent mental health services according to their clinical judgement. Methods Analytical approach:A multicentre randomised controlled trial was undertaken. The time horizon was 12 months. The authors stated that the perspective was broad and included the costs to the health, social care, education, and criminal justice sectors, while the costs to families were reported separately.
Effectiveness data:The effectiveness data were from a prospective, two arm, single assessor blinded, parallel, randomised controlled trial, of patients from eight child and adolescent mental health services. In total, 366 patients were randomised, with 183 in each group. Four were lost to follow-up in the intervention group and three in the routine care group. The baseline characteristics were balanced across groups. Research assessors, who were blind to treatment allocation, conducted interviews with the participants every three months. Research therapists, who were not blind to treatment allocation, conducted monthly interviews. Information from these interviews was used to derive the main clinical effectiveness estimate, which was the frequency of episodes of self-harm.
Monetary benefit and utility valuations:Not relevant.
Measure of benefit:The measure of benefit was the proportion of young people who had not self-harmed over the preceding six months. Secondary outcomes included the severity of self-harm, mood disorder, depressive symptoms, suicidal ideation, and global functioning.
Cost data:The resource types included hospitalisations, interventions (staff salaries and overheads), indirect therapist time, participant travel, productivity losses incurred by parents, and education and criminal justice costs. The unit costs were from publicly available sources, such as NHS reference costs and the British National Formulary. Travel costs were reported by the relevant individuals. The costs were analysed using ordinary least-squares regression and reported in 2005 to 2006 UK pounds sterling (£).
Analysis of uncertainty:One-way sensitivity analyses were undertaken by varying the therapist salaries, excluding high cost outliers, adding patient travel and parent productivity costs, and using multiple imputation for missing resource data. Nonparametric bootstrapping of the mean costs and effects of the interventions was performed to produce a distribution of possible incremental values. Results The adjusted proportional odds ratio for frequency of self-harm with group therapy versus routine care was 0.99 (95% CI 0.68 to 1.44) at six months and 0.88 (95% CI 0.59 to 1.30) at 12 months. For all participants, significant improvements were shown from baseline to 12-month follow-up, but no significant differences occurred in any of the secondary outcomes.
The total mean costs were £21,781 (SD 38,794) for group therapy and £15,372 (SD 24,981) for routine care. The increase in mean costs with group therapy was not statistically significant at £6,408 (95% CI 1,416 to 10,782). The incremental cost-effectiveness ratio for group therapy was £2,020 per 1% increase in the proportion of young people not self-harming.
One-way sensitivity analyses showed that the results were stable to changes in some variables. The authors reported a 12% to 28% chance that group therapy would be considered more cost-effective than routine care. Authors' conclusions The authors concluded that the group therapy for adolescents at risk of self-harming was not a cost-effective addition to routine care, at any likely willingness-to-pay threshold. CRD commentary Interventions:The interventions were well described and appear to have been appropriate comparators. The group intervention might be acceptable in other settings.
Effectiveness/benefits:The evidence of effectiveness was based on a large randomised trial, which should have a high level of internal validity. Appropriate details of the trial were provided and it seems that the authors accounted for some potential confounding factors within the trial. The measure of benefit appears to have been appropriate for this intervention, but it was not generalisable, which will make it difficult to compare the results of this study with those of other studies.
Costs:The perspective was stated to be broad and appears to have included all those resources relevant to a societal perspective, except that productivity costs were only included in the sensitivity analysis and not the main analysis. The resource types and quantities were described and presented separately. The sources appear to have been of good quality and the costs appear to have been appropriately adjusted for inflation.
Analysis and results:The analytic approach appears to have been valid. The health outcomes and costs were combined into an incremental cost-effectiveness ratio and some sensitivity analyses were undertaken. The results of the bootstrapping analysis were not presented, nor illustrated, but were reported to be similar.
Concluding remarks:The methods, analyses, and results were mostly clear and comprehensive. The conclusions reached by the authors were a sound assessment of the findings and appear to be appropriate. Funding Funded by the Health Foundation, UK. Bibliographic details Green JM, Wood AJ, Kerfoot MJ, Trainor G, Roberts C, Rothwell J, Woodham A, Ayodeji E, Barrett B, Byford S, Harrington R. Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation. BMJ 2011; 342:d682 Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Child; Conduct Disorder /complications; Cost-Benefit Analysis; Depressive Disorder /complications; Female; Humans; Male; Psychotherapy, Group /economics; Recurrence; Self-Injurious Behavior /economics /psychology /therapy; Single-Blind Method; Stress, Psychological /complications; Treatment Outcome AccessionNumber 22011000622 Date bibliographic record published 15/06/2011 Date abstract record published 21/09/2011 |
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