Cost-Effectiveness of Different Formats for Delivery of Cognitive Behavioral Therapy for Depression: A Systematic Review Based Economic Model.

OBJECTIVES: Cognitive behavioral therapy (CBT) is an effective treatment for depression. Different CBT delivery formats (face-to-face [F2F], multimedia, and hybrid) and intensities have been used to expand access to the treatment. The aim of this study is to estimate the long-term cost-effectiveness of different CBT delivery modes. METHODS: A decision-analytic model was developed to evaluate the cost-effectiveness of different CBT delivery modes and variations in intensity in comparison with treatment as usual (TAU). The model covered an average treatment period of 4 months with a 5-year follow-up period. The model was populated using a systematic review of randomized controlled trials and various sources from the literature. RESULTS: Incremental cost-effectiveness ratios of treatments compared with the next best option after excluding all the dominated and extended dominated options are: £209/quality-adjusted life year (QALY) for 6 (sessions) × 30 (minutes) F2F-CBT versus TAU; £4 453/QALY for 8 × 30 F2F versus 6 × 30 F2F; £12 216/QALY for 8 × 60 F2F versus 8 × 30 F2F; and £43 072/QALY for 16 × 60 F2F versus 8 × 60 F2F. The treatment with the highest net monetary benefit for thresholds of £20 000 to £30 000/QALY was 8 × 30 F2F-CBT. Probabilistic sensitivity analysis illustrated 6 × 30 F2F-CBT had the highest probability (32.8%) of being cost-effective at £20 000/QALY; 16 × 60 F2F-CBT had the highest probability (31.0%) at £30 000/QALY. CONCLUSIONS: All CBT delivery modes on top of TAU were found to be more cost-effective than TAU alone. Four F2F-CBT options (6 × 30, 8 × 30, 8 × 60, 16 × 60) are on the cost-effectiveness frontier. F2F-CBT with intensities of 6 × 30 and 16 × 60 had the highest probabilities of being cost-effective. The results, however, should be interpreted with caution owing to the high level of uncertainty.

The impact of leishmaniasis on mental health and psychosocial well-being: A systematic review.

BACKGROUND: Leishmaniasis is a neglected tropical parasitic disease endemic in South Asia, East Africa, Latin America and the Middle East. It is associated with low socioeconomic status (SES) and responsible for considerable mortality and morbidity. Reports suggest that patients with leishmaniasis may have a higher risk of mental illness (MI), psychosocial morbidity (PM) and reduced quality of life (QoL), but this is not well characterised. The aim of this study was to conduct a systematic review to assess the reported impact of leishmaniasis on mental health and psychosocial wellbeing. METHODS: A systematic review of the literature was carried out. Pre-specified criteria were applied to identify publications including observational quantitative studies or systematic reviews. Two reviewers screened all of the titles, abstracts and full-studies and a third reviewer was consulted for disagreements. Data was extracted from papers meeting the criteria and quality appraisal of the methods was performed using the Newcastle-Ottawa Scale or the Risk of Bias in Systematic Review tool. RESULTS: A total of 14 studies were identified from 12,517 records. Nine cross-sectional, three case-control, one cohort study and one systematic review were included. Eleven assessed MI outcomes and were measured with tools specifically designed for this; nine measured PM and 12 measured QoL using validated measurement tools. Quality appraisal of the studies showed that six were of good quality. Cutaneous leishmaniasis and post kala-azar dermal leishmaniasis showed evidence of associated MI and PM including depression, anxiety and stigma, while all forms of disease showed decreased QoL. The findings were used to inform a proposed model and conceptual framework to show the possible links between leishmaniasis and mental health outcomes. CONCLUSION: There is evidence that leishmaniasis has an impact on MI, PM or QoL of patients and their families and this occurs in all the main subtypes of the disease. There are however large gaps in the evidence. Further research is required to understand the full extent of this problem and its mechanistic basis.

A cohort study of adherence to antidepressants in primary care: the influence of antidepressant concerns and treatment preferences.

OBJECTIVE: Clinical guidelines recommend that antidepressant treatment should be continued for a minimum of 6 months following response in depression and anxiety disorders. However, adherence to antidepressants is low. This prospective cohort study investigated the influence of patients' antidepressant concerns, treatment preferences, and illness perceptions on adherence to antidepressants over a 6-month period. METHOD: A cohort of 178 patients aged 18 to 74 years and newly issued with a prescription for antidepressants to treat any condition was followed up prospectively at 5 primary care practices in Southeast England. Adherence was measured through self-report and prescription refill data. Patient perceptions were quantified using validated outcome measures, the Beliefs about Medicine Questionnaire and the Illness Perception Questionnaire, at 4 timepoints. Patient treatment preferences were recorded using a specially designed questionnaire. Data collection took place between September 2000 and May 2002. RESULTS: Of 147 participants (83%) who completed the study, 19% persisted with antidepressants in accordance with guideline recommendations throughout the 6-month period. Specific concern about antidepressant side effects (OR = 3.30, 95% CI = 2.20 to 4.97) and general worry about taking antidepressants (OR = 1.65, 95% CI = 1.13 to 2.40) were independent predictors of antidepressant nonuse. Preference for different treatment/uncertainty about preferred treatment was also a strong predictor (OR = 3.82, 95% CI = 1.35 to 10.77). However, illness perceptions were not associated with adherence. CONCLUSIONS: Concerns about antidepressants and a mismatch between patients' preferred and prescribed treatment act as significant barriers to sustained adherence. This study highlights the central role of the patient-physician partnership in exploring antidepressant concerns, working with treatment preferences, and providing supportive continued management. The findings may inform the development of interventions within primary care programs to enhance commitment to treatment for common mental disorders.