Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care: randomised controlled trial. A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients. The CPN-GP study. Life satisfaction and psychosocial functioning in chronic depression: effect of acute treatment with antidepressants. Impact of improved depression treatment in primary care on daily functioning and disability. Evaluation of the cost effectiveness of escitalopram versus venlafaxine XR in major depressive disorder. The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine. Psychodynamic psychotherapy and clomipramine in the treatment of major depression. Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. The effect of improving primary care depression management on employee absenteeism and productivity. A randomized trial. The cost-effectiveness of mirtazapine versus paroxetine in treating people with depression in primary care.
Cognitive-behavioural therapy (CBT) is effective for treating anxiety and depression in primary care, but there is a shortage of therapists. Computer-delivered treatment may be a viable alternative.
                To assess the cost-effectiveness of computer-delivered CBT.
                A sample of people with depression or anxiety were randomised to usual care (n=128) or computer-delivered CBT (n=146). Costs were available for 123 and 138 participants, respectively. Costs and depression scores were combined using the net benefit approach.
                Service costs were 40 British pounds (90% CI - 28 British pounds to 148 British pounds) higher over 8 months for computer-delivered CBT. Lost-employment costs were 407 British pounds (90% CI 196 British pounds to 586 British pounds) less for this group. Valuing a 1-unit improvement on the Beck Depression Inventory at 40 British pounds, there is an 81% chance that computer-delivered CBT is cost-effective, and it revealed a highly competitive cost per quality-adjusted life year.
                Computer-delivered CBT has a high probability of being cost-effective, even if a modest value is placed on unit improvements in depression. To compare the effectiveness of community mental health nurse (CMHN) problem-solving and generic CMHN care, against usual general practitioner (GP) care in reducing symptoms, alleviating problems, and improving social functioning and quality of life for people living in the community with common mental disorders; and to undertake a cost comparison of each CMHN treatment compared with usual GP care.
                A pragmatic, randomised controlled trial with three arms: CMHN problem-solving, generic CMHN care and usual GP care.
                General practices in two southern English counties were included in the study. CMHNs were employed by local NHS trusts providing community mental health services.
                Participants were GP patients aged 18--65 years with a new episode of anxiety, depression or reaction to life difficulties and had to score at least 3 points on the General Health Questionnaire-12 screening tool. Symptoms had to be present for a minimum of 4 weeks but no longer than 6 months.
                Patients were randomised to one of three groups: (1) CMHN problem-solving treatment, (2) generic CMHN treatment, or (3) usual GP care. All three groups of patients remained free to consult their GPs throughout the course of the study, and could be prescribed psychotropic drug treatments.
                Patients were assessed at baseline, and 8 weeks and 26 weeks after randomisation. The primary outcome measure was psychological symptoms measured on the Clinical Interview Schedule -- Revised. Other measures included social functioning, health-related quality of life, problem severity and satisfaction. The economic outcomes were evaluated with a cost--utility analysis.
                Twenty-four CMHNs were trained to provide problem-solving under supervision, and another 29 were referred patients for generic support. In total, 247 patients were randomised to the three arms of the study, referred by 98 GPs in 62 practices. All three groups of patients were greatly improved by the 8-week follow-up. No significant differences were found between the groups at 8 weeks or 26 weeks in symptoms, social functioning or quality of life. Greater satisfaction with treatment was found in the CMHN groups. CMHN care represented a significant additional health service cost and there were no savings in sickness absence.
                The study found that specialist mental health nurse support is no better than support from GPs for patients with anxiety, depression and reactions to life difficulties. The results suggest that healthcare providers could consider adopting policies of restricting referrals of unselected patients with common mental disorders to specialist CMHNs, although there may be other roles in primary care that CMHNs could play effectively. Further research should address the predictors of chronicity in common mental disorders and target extra treatment. More research is also needed into the effectiveness and cost-effectiveness of problem-solving treatment for other disorders, of facilitated self-help treatments for common mental disorders and of CMHN care for people with severe and enduring mental illnesses, as well as the prevention of mental disorders. Social functioning was evaluated in 61 chronically depressed adults with early onset. Patients were treated for 6 weeks in a double-blind trial of phenelzine, imipramine, L-deprenyl, or placebo and functioning was reassessed. The posttreatment social functioning of patients who received drug treatment was superior to the placebo group in the following areas: work functioning, house functioning, relationship with relatives, sex frequency and life satisfaction. These results suggest that psychosocial impairment in some chronic depressives may be a sequaela of depression, rather than a global manifestation of characterological pathology. Few data are available regarding the impact of improved depression treatment on daily functioning and disability.
                In two studies of more intensive depression treatment in primary care, patients initiating antidepressant treatment were randomly assigned to either usual care or to a collaborative management programme including patient education, on-site mental health treatment, adjustment of antidepressant medication, behavioural activation and monitoring of medication adherence. Assessments at baseline as well as 4 and 7 months included several measures of impairment, daily functioning and disability: self-rated overall health, number of bodily pains, number of somatization symptoms, changes in work due to health, reduction in leisure activities due to health, number of disability days and number of restricted activity days.
                Average data from the 4- and 7-month assessments in both studies, intervention patients reported fewer somatic symptoms (OR 0.68, 95% CI 0.46, 0.99) and more favourable overall health (OR 0.50, 95% CI 0.28, 0.91). While intervention patients fared better on other measures of functional impairment and disability, none of these differences reached statistical significance.
                More effective acute-phase depression treatment reduced somatic distress and improved self-rated overall health. The absence of a significant intervention effect on other disability measures may reflect the brief treatment and follow-up period and the influence of other individual and environmental factors on disability. To assess the relative cost effectiveness of escitalopram compared with venlafaxine XR in patients with major depressive disorder (MDD).
                An economic evaluation was conducted alongside a double-blind, multinational, randomised clinical trial and examined the costs and quality of life of 251 patients taking escitalopram versus venlafaxine. Outpatients fulfilling criteria for MDD were randomised to receive oral escitalopram 10-20 mg/day or venlafaxine 75-150 mg/day for 8 weeks. Patient-reported outcomes (EuroQOL questionnaire, Quality of Life Depression Scale), use of medical services and absence from work (relating to the previous 3 months) were recorded at baseline, with repeated measurements at week 8. Unit costs in year values were applied to the resource utilisation data. A cost-effectiveness analysis was performed using the EuroQOL score as the effectiveness measure. The perspective was that of the healthcare payer, with a societal perspective considered in a sensitivity analysis.
                Statistically significant improvements in patient-reported outcomes (vs baseline) were observed in both groups after 8 weeks' treatment. Patients treated with escitalopram tended to report fewer problems on the EuroQOL dimensions than venlafaxine recipients. Mean per-patient costs in euros (euro, year 2003 values) for the escitalopram group, compared with the venlafaxine group, were 32% lower (110 euros vs 161euros) from a healthcare perspective, although this was not a statistically significant difference. Differences were related to lower drug acquisition costs and fewer hospitalisations for escitalopram than venlafaxine recipients. A multivariate model adjusting for baseline characteristics showed that escitalopram reduced direct costs compared with venlafaxine (p = 0.007). Bootstrapped distributions of the incremental cost-effectiveness ratios also showed similar effectiveness but lower costs for escitalopram compared with venlafaxine. Inclusion of indirect costs led to similar results.
                This prospective economic analysis suggests that escitalopram has similar effectiveness to venlafaxine in the treatment of MDD, but may be associated with lower healthcare costs. These findings are consistent with previously published economic evaluations. Previous research has suggested that depressed patients, and particularly chronically depressed patients, have significant impairments in many areas of their lives. While previous studies suggested that these "psychosocial" impairments improve following pharmacologic treatment, no large scale definitive study using multiple measures of psychosocial functioning has been reported.
                We assessed multiple domains of psychosocial functioning using interviewer-rated and self-report measures within the context of a 12-week acute treatment trial of sertraline and imipramine for patients with chronic depression (double depression and chronic major depression). We also compared the psychosocial functioning data of this sample before and after treatment with normative data available from published community samples.
                Chronically depressed patients manifested severe impairments in psychosocial functioning at baseline. After treatment with sertraline or imipramine, psychosocial functioning improved significantly. Significant improvements appeared relatively early in treatment (week 4). Despite these highly significant improvements in functioning during acute treatment, the study sample as a whole did not achieve levels of psychosocial functioning comparable to a comparator nondepressed community sample. However, patients who reached full symptomatic response (remission) during acute treatment did have levels of psychosocial functioning in most areas at endpoint that approached or equaled those of community samples.
                These results indicate that successful antidepressant treatment with sertraline or imipramine can alleviate the severe psychosocial impairments found in chronic depression. The authors compared a combination of clomipramine and psychodynamic psychotherapy with clomipramine alone in a randomized controlled trial among patients with major depression.
                Seventy-four patients between the ages of 20 and 65 years who were assigned to ten weeks of acute outpatient treatment for major depression were studied. Bipolar disorder, psychotic symptoms, severe substance dependence, organic disorder, past intolerance to clomipramine, and mental retardation were exclusion criteria.
                Marked improvement was noted in both treatment groups. Combined treatment was associated with less treatment failure and better work adjustment at ten weeks and with better global functioning and lower hospitalization rates at discharge. A cost savings of 2,311 dollars per patient in the combined treatment group, associated with lower rates of hospitalization and fewer lost work days, exceeded the expenditures related to providing psychotherapy.
                Provision of supplemental psychodynamic psychotherapy to patients with major depression who are receiving antidepressant medication is cost-effective. Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.
                To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.
                Group-level randomized controlled trial conducted June 1996 to July 1999.
                Forty-six primary care clinics in 6 community-based managed care organizations.
                One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.
                Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.
                Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions.
                Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period.
                Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders. To test whether an intervention to improve primary care depression management significantly improves productivity at work and absenteeism over 2 years.
                Twelve community primary care practices recruiting depressed primary care patients identified in a previsit screening.
                Practices were stratified by depression treatment patterns before randomization to enhanced or usual care. After delivering brief training, enhanced care clinicians provided improved depression management over 24 months. The research team evaluated productivity and absenteeism at baseline, 6, 12, 18, and 24 months in 326 patients who reported full-or part-time work at one or more completed waves.
                Employed patients in the enhanced care condition reported 6.1% greater productivity and 22.8% less absenteeism over 2 years. Consistent with its impact on depression severity and emotional role functioning, intervention effects were more observable in consistently employed subjects where the intervention improved productivity by 8.2% over 2 years at an estimated annual value of US 1982 dollars per depressed full-time equivalent and reduced absenteeism by 28.4% or 12.3 days over 2 years at an estimated annual value of US 619 dollars per depressed full-time equivalent.
                This trial, which is the first to our knowledge to demonstrate that improving the quality of care for any chronic disease has positive consequences for productivity and absenteeism, encourages formal cost-benefit research to assess the potential return-on-investment employers of stable workforces can realize from using their purchasing power to encourage better depression treatment for their employees. Currently, there are no data available comparing cost-effectiveness of two antidepressants in the primary care setting in the UK. Alongside a randomized, double-blind, 24-week study of mirtazapine and paroxetine, data were prospectively collected on patients' use of hospital and non-hospital services and days off work. Costs were estimated in each treatment arm from National Health Service (NHS) and societal perspectives, and were compared with selected outcome measures (numbers of 17-item Hamilton Rating Scale for Depression (17-HAMD) responders and changes in Quality of Life in Depression Scale scores between baseline and 24-week endpoint) to explore and compare relative cost-effectiveness. Mirtazapine treatment resulted in a statistically significantly greater improvement in quality of life than paroxetine at endpoint (P=0.021). Although the 17-HAMD response rates were higher for the mirtazapine users at endpoint, the difference (7%) was not statistically significant (P=0.31). However, mean total societal costs per patient were 375 pounds less with mirtazapine (1850 pounds) compared to paroxetine (2225 pounds; P=0.32). Mean total NHS costs per patient were also lower (120 pounds) with mirtazapine (1408 pounds) compared to paroxetine (1528 pounds). The advantage for mirtazapine remained present on all variables analysed after performing sensitivity analyses. The results suggest that mirtazapine may be a cost-effective treatment choice compared to paroxetine for depression in a primary care setting.
Based on a heterogeneous sample of studies, there is currently no evidence of an effect of medication alone, enhanced primary care, psychological interventions or the combination of those with medication on sickness absence of depressed workers. In future RCTs, interventions should specifically address work issues, and occupational outcomes should be used to measure the effect..