Dataset Information

Cost-Utility of Internet-Based Cognitive Behavioral Therapy in Unipolar Depression: A Markov Model Simulation.

ABSTRACT:

Background and objective

Unipolar depression is the most common form of depression and demand for treatment, such as psychotherapy, is high. However, waiting times for psychotherapy often considerably exceed their recommended maximum. As a potentially less costly alternative treatment, internet-based cognitive behavior therapy (ICBT) might help reduce waiting times. We therefore analyzed the cost-utility of ICBT compared to face-to-face CBT (FCBT) as an active control treatment, taking differences in waiting time into account.

Methods

We constructed a Markov model to simulate costs and health outcomes measured in quality-adjusted life years (QALYs) for ICBT and FCBT in Germany. We modeled a time horizon of 3 years using six states (remission, depressed, spontaneous remission, undergoing treatment, treatment finished, death). The societal perspective was adopted. We obtained parameters for transition probabilities, depression-specific QoL, and cost data from the literature. Deterministic and probabilistic sensitivity analyses were conducted. Within a scenario analysis, we simulated different time-to-treatment combinations. Half-cycle correction was applied.

Results

In our simulation, ICBT generated 0.260 QALYs and saved €2536 per patient compared to FCBT. Our deterministic sensitivity analysis suggests that the base-case results were largely unaffected by parameter uncertainty and are therefore robust. Our probabilistic sensitivity analysis suggests that ICBT is highly likely to be more effective (91.5%), less costly (76.0%), and the dominant strategy (69.7%) compared to FCBT. The scenario analysis revealed that the base-case results are robust to variations in time-to-treatment differences.

Conclusion

ICBT has a strong potential to balance demand and supply of CBT in unipolar depression by reducing therapist time per patient. It is highly likely to generate more QALYs and reduce health care expenditure. In addition, ICBT may have further positive external effects, such as freeing up capacities for the most severely depressed patients.

SUBMITTER: Baumann M

PROVIDER: S-EPMC7347685 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Publications

Cost-Utility of Internet-Based Cognitive Behavioral Therapy in Unipolar Depression: A Markov Model Simulation.

Baumann Mathias M Stargardt Tom T Frey Simon S

Applied health economics and health policy 20200801 4

<h4>Background and objective</h4>Unipolar depression is the most common form of depression and demand for treatment, such as psychotherapy, is high. However, waiting times for psychotherapy often considerably exceed their recommended maximum. As a potentially less costly alternative treatment, internet-based cognitive behavior therapy (ICBT) might help reduce waiting times. We therefore analyzed the cost-utility of ICBT compared to face-to-face CBT (FCBT) as an active control treatment, taking d ...[more]

PMID: 32060822

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Project description:BackgroundMajor depressive disorder is a chronic condition; its prevalence is expected to grow with the aging trend of high-income countries. Internet-based cognitive-behavioral therapy has proven efficacy in treating major depressive disorder.ObjectiveThe objective of this study was to assess the cost-effectiveness of implementing a community internet-based cognitive behavioral therapy intervention (Super@, the Spanish program for the MasterMind project) for treating major depressive disorder.MethodsThe cost-effectiveness of the Super@ program was assessed with the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing tool, using a 3-state Markov model. Data from the cost and effectiveness of the intervention were prospectively collected from the implementation of the program by a health care provider in Badalona, Spain; the corresponding data for usual care were gathered from the literature. The health states, transition probabilities, and utilities were computed using Patient Health Questionnaire-9 scores.ResultsThe analysis was performed using data from 229 participants using the Super@ program. Results showed that the intervention was more costly than usual care; the discounted (3%) and nondiscounted incremental cost-effectiveness ratios were €29,367 and €26,484 per quality-adjusted life-year, respectively (approximately US $35,299 and $31,833, respectively). The intervention was cost-effective based on the €30,000 willingness-to-pay threshold typically applied in Spain (equivalent to approximately $36,060). According to the deterministic sensitivity analyses, the potential reduction of costs associated with intervention scale-up would reduce the incremental cost-effectiveness ratio of the intervention, although it remained more costly than usual care. A discount in the incremental effects up to 5% exceeded the willingness-to-pay threshold of €30,000.ConclusionsThe Super@ program, an internet-based cognitive behavioral therapy intervention for treating major depressive disorder, cost more than treatment as usual. Nevertheless, its implementation in Spain would be cost-effective from health care and societal perspectives, given the willingness-to-pay threshold of €30,000 compared with treatment as usual.

Project description:BackgroundUnguided internet-based cognitive behavioral therapy (ICBT) has been proven effective for major depressive disorder (MDD). However, few studies have examined its cost-effectiveness in low-resource countries and under nonspecialist routine care.ObjectiveThis study aimed to evaluate the short- and long-term cost utility of unguided ICBT compared to a waitlist control for persons with MDD from the perspectives of society and the health care system.MethodsThis analysis was implemented alongside an 8-week 2-arm randomized controlled trial with a 12-month follow-up period conducted in Shenzhen, China. Outcomes including cost and health utility were collected at the pretreatment and posttreatment time points and 3, 6, and 12 months after the intervention. Direct medical costs and indirect costs were prospectively collected using the hospital information system and the Sheehan Disability Scale. Health outcomes were measured using the Chinese version of the Short-Form Six-Dimension health index. The primary outcome was incremental cost utility ratio (ICUR) expressed as the difference in costs between 2 therapies by the difference in quality-adjusted life years (QALYs). The seemingly unrelated regression model and the bootstrap method were performed to estimate adjusted ICURs. Cost-effectiveness planes and cost-effectiveness acceptability curves were used to demonstrate uncertainty. A series of scenario analyses were conducted to verify the robustness of base-case results.ResultsIn total, 244 participants with MDD were randomly allocated to the ICBT (n=122, 50%) or waitlist control (n=122, 50%) groups. At the pretreatment time point, no statistically significant difference was observed in direct medical cost (P=.41), indirect cost (P=.10), or health utility (P=.11) between the 2 groups. In the base-case analysis, the ICBT group reported higher direct medical costs and better quality of life but lower total costs at the posttreatment time point. The adjusted ICURs at the posttreatment time point were CN ¥-194,720.38 (US $-26,551.50; 95% CI CN ¥-198,766.78 to CN ¥-190,673.98 [US $-27,103.20 to US $-25,999.70]) and CN ¥49,700.33 (US $6776.99; 95% CI CN ¥46,626.34-CN ¥52,774.31 [US $6357.83-$7196.15]) per QALY from the societal and health care system perspectives, respectively, with a probability of unguided ICBT being cost-effective of 75.93% and 54.4%, respectively, if the willingness to pay was set at 1 time the per-capita gross domestic product. In the scenario analyses, the probabilities increased to 76.85% and 77.61%, respectively, indicating the potential of ICBT to be cost-effective over the long term.ConclusionsUnguided ICBT is a cost-effective treatment for MDD. This intervention not only helps patients with MDD improve clinically but also generates societal savings. These findings provide health economic evidence for a potential scalable MDD treatment method in low- and middle-income countries.Trial registrationChinese Clinical Trial Registry (ChiCTR) ChiCTR2100046425; https://tinyurl.com/bdcrj4zv.

Project description:BackgroundScientific implementation findings relevant to the implementation of internet-delivered cognitive behavioral therapy (iCBT) for depression and anxiety in adults remain sparse and scattered across different sources of published information. Identifying evidence-based factors that influence the implementation of iCBT is key to successfully using iCBT in real-world clinical settings.ObjectiveThis systematic review evaluated the following: (1) aspects that research articles postulate as important for the implementation of iCBT and (2) aspects relevant to the day-to-day running of iCBT services. A mixed methods systematic review using a convergent synthesis design was conducted to bring together evidence across this sparse literature consisting of divergent scientific article types to investigate the implementation of iCBT for depression and anxiety in adults.MethodsWe searched the PsycINFO, PsycArticles, MEDLINE, CINAHL Complete, and Embase databases for any published peer-reviewed scientific articles that report on the implementation of iCBT for depression or anxiety disorders in adults. A total of 40 articles spanning the case study, commentary, meta-analysis, mixed methods study, pilot randomized controlled trial, randomized controlled trial, qualitative study, quantitative study, review, and systematic review article types were identified as eligible for this mixed methods review. Data were analyzed qualitatively using the descriptive-interpretive approach.ResultsThe first domain highlighted the impact of therapist and patient attitudes when implementing iCBT, the superiority of guided iCBT over unguided iCBT, its noninferiority to equivalent face-to-face treatments, and its utility outside of the original target of mild-to-moderate depression and anxiety. In total, 3 subdomains were identified under the second domain: (1) the management of iCBT in the workplace, detailing the importance of managing the iCBT service, related staff, and their motivations for using it; (2) the practice of iCBT in the workplace, describing the therapeutic aspects of iCBT provision, such as the provision of support, the background of supporters, and screening procedures; and (3) contextual considerations, detailing the impact of governmental legislation on therapy conducted over the internet, the lack of an iCBT workforce as a limiting factor, and the cost estimates associated with iCBT provision.ConclusionsBroadly, the findings describe several aspects that should be taken into account when researchers or practitioners implement iCBT as part of their work. However, the findings should be interpreted with caution, as the articles reviewed spanned many article types, and few of the included studies were directly focused on evaluating the implementation of iCBT. While findings provide insight into important factors to consider during iCBT implementation, these findings and their limitations highlight the need for more implementation-specific research in this area.

Project description:BACKGROUND:Major depression is a world-wide problem that can be treated with various forms of psychotherapy. There is strong research support for treating major depression using cognitive behavior therapy delivered in the format of guided self-help via the Internet (ICBT). Recent research also suggests that psychodynamic psychotherapy can be delivered as guided self-help via the Internet (IPDT) and that it seem to be as effective as ICBT for mild to moderate depression. However, no head-to-head comparison between the two treatments exists. In the field of Internet interventions it is largely unexplored if treatment preference affects outcome and adherence. METHODS:Participants were allocated to IPDT or ICBT based on their stated preference. More than half of the participants preferred ICBT (N = 30) over IPDT (N = 14). Differences in efficacy between treatments were explored. Correlations between strength of preference and treatment outcome, adherence to treatment and completion of the whole treatment program were explored. Data were collected before and after treatment, as well as in a 7-month follow-up. RESULTS:During the treatment period, both programs performed equally well in reducing symptoms. More participants who received IPDT completed the entire program. At follow-up, mixed-effects models showed that participants who chose ICBT improved more in terms of quality of life. The ICBT group also had a significant increase in participants who recovered from their depression from post-treatment to follow-up. Exploratory analyses indicated that strength of preference was correlated with adherence to treatment and completion of the whole program, and long-term outcome for the ICBT group. CONCLUSIONS:Few differences were found during the acute treatment phase, but the long-term effects are in favor of ICBT. Strength of preference for treatment seems to have a predictive value. Further research comparing the efficacy of ICBT and IPDT, and the effects of preference matching and strength of preference, is warranted. TRIAL REGISTRATION:This trial is a continuation of the study registered as NCT01324050 at Clinicaltrials.gov.

Project description:BackgroundDepression is a hidden burden, yet it is a leading cause of disability worldwide. Despite the adverse effects of depression, fewer than one-third of patients receive care. Internet-based cognitive behavioral therapy (i-CBT) is an effective treatment for depression, and combining i-CBT with supervised care could make the therapy scalable and effective. A stepped care model is a framework for beginning treatment with an effective and low-intensity intervention while adapting care based on the patient's needs.ObjectiveThis study investigated the efficacy of a stepped care i-CBT model for depression based on changes in self-reported depressive symptoms.MethodsIn this single-blinded, randomized controlled trial, participants were allocated to either the i-CBT-only group (28/56, 50%) or the i-CBT with stepped care group (28/56, 50%). Both groups received a 13-week i-CBT program tailored for depression. The i-CBT program was provided through a secure, online mental health clinic called the Online Psychotherapy Tool. Participants read through the sessions and completed the assignments related to each session. Participants in the stepped care group received additional interventions from their care provider based on standard questionnaire scores (ie, Patient Health Questionnaire-9 [PHQ-9], Quick Inventory of Depressive Symptomatology [QIDS], and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form) and their assignment responses. From lowest to highest intensity, the additional interventions included SMS text messages, phone calls, video calls, or a video call with a psychiatrist.ResultsFor this study, 56 participants were recruited to complete an i-CBT program (n=28, 50%; mean age 37.9; SD 13.08 y; 7/28, 27% were men) or an i-CBT with stepped care program (n=28, 50%; mean age 40.6; SD 14.28 y; 11/28, 42% were men). The results of this study indicate that the i-CBT program was effective in significantly reducing depressive symptoms, as measured by the PHQ-9 (F4,80=9.95; P<.001) and QIDS (F2,28=5.73; P=.008); however, there were no significant differences in the reduction of depressive symptoms between the 2 groups (PHQ-9: F4,80=0.43; P=.78; QIDS: F2,28=3.05; P=.06). The stepped care group was not significantly better in reducing depressive symptoms than the i-CBT group (PHQ-9, P=.79; QIDS, P=.06). Although there were no significant differences observed between the number of participants who completed the program between the groups (χ21=2.6; P=.10), participants in the stepped care group, on average, participated in more sessions than those who prematurely terminated participation in the i-CBT group (t55=-2; P=.03; 95% CI -4.83 to -0.002).ConclusionsImplementing a stepped care approach in i-CBT is an effective treatment for depression, and the stepped care model can assist patients to complete more sessions in their treatment.Trial registrationClinicaltrials.gov NCT04747873; https://clinicaltrials.gov/study/NCT04747873.

Project description:ImportanceThere is limited understanding of how complex evidence-based psychological interventions such as cognitive behavioral therapy (CBT) for depression work. Identifying active ingredients may help to make therapy more potent, brief, and scalable.ObjectiveTo test the individual main effects and interactions of 7 treatment components within internet-delivered CBT for depression to investigate its active ingredients.Design, setting, and participantsThis randomized optimization trial using a 32-condition, balanced, fractional factorial optimization experiment (IMPROVE-2) recruited adults with depression (Patient Health Questionnaire-9 [PHQ-9] score ≥10) from internet advertising and the UK National Health Service Improving Access to Psychological Therapies service. Participants were randomized from July 7, 2015, to March 29, 2017, with follow-up for 6 months after treatment until December 29, 2017. Data were analyzed from July 2018 to April 2023.InterventionsParticipants were randomized with equal probability to 7 experimental factors within the internet CBT platform, each reflecting the presence vs absence of specific treatment components (activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, absorption, and self-compassion training).Main outcomes and measuresThe primary outcome was depression symptoms (PHQ-9 score). Secondary outcomes include anxiety symptoms and work, home, and social functioning.ResultsAmong 767 participants (mean age [SD] age, 38.5 [11.62] years; range, 18-76 years; 635 women [82.8%]), 506 (66%) completed the 6-month posttreatment follow-up. On average, participants receiving internet-delivered CBT had reduced depression (pre-to-posttreatment difference in PHQ-9 score, -7.79 [90% CI, -8.21 to -7.37]; 6-month follow-up difference in PHQ-9 score, -8.63 [90% CI, -9.04 to -8.22]). A baseline score-adjusted analysis of covariance model using effect-coded intervention variables (-1 or +1) found no main effect on depression symptoms for the presence vs absence of activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, or self-compassion training (posttreatment: largest difference in PHQ-9 score [functional analysis], -0.09 [90% CI, -0.56 to 0.39]; 6-month follow-up: largest difference in PHQ-9 score [relaxation], -0.18 [90% CI, -0.61 to 0.25]). Only absorption training had a significant main effect on depressive symptoms at 6-month follow-up (posttreatment difference in PHQ-9 score, 0.21 [90% CI, -0.27 to 0.68]; 6-month follow-up difference in PHQ-9 score, -0.54, [90% CI, -0.97 to -0.11]).Conclusions and relevanceIn this randomized optimization trial, all components of internet-delivered CBT except absorption training did not significantly reduce depression symptoms relative to their absence despite an overall average reduction in symptoms. The findings suggest that treatment benefit from internet-delivered CBT probably accrues from spontaneous remission, factors common to all CBT components (eg, structure, making active plans), and nonspecific therapy factors (eg, positive expectancy), with the possible exception of absorption focused on enhancing direct contact with positive reinforcers.Trial registrationisrctn.org Identifier: ISRCTN24117387.

Project description:BackgroundPostpartum depression (PPD) and postpartum anxiety (PPA) are often comorbid and are associated with significant personal and economic costs. Fewer than half of the mothers experiencing PPD or PPA symptoms receive face-to-face treatment, suggesting a need for alternative delivery formats such as internet-delivered cognitive behavioral therapy (ICBT).ObjectiveThis pilot study aimed to examine the impact of a therapist-assisted, transdiagnostic ICBT program on symptoms of PPD and PPA, as there is only one previous study on transdiagnostic ICBT with this population, which did not include therapist assistance.MethodsClients endorsing the symptoms of PPD or PPA (N=63) were randomized to an 8-week transdiagnostic ICBT course (Wellbeing Course for New Moms) or to treatment as usual (TAU). Clients completed measures of depression, anxiety, stress, postnatal bonding, and relationship satisfaction, as well as measures of treatment satisfaction and therapeutic alliance, before treatment, after treatment, and at the 1-month follow-up. Outcome measures were also completed at the 6-month follow-up for clients who completed the ICBT course.ResultsBoth the ICBT and TAU groups experienced statistically significant improvements over time. The ICBT group experienced larger improvements after treatment and at the 1-month follow-up on more measures than the TAU group, with medium between-group Cohen d effects on primary outcome measures for anxiety (Cohen d=0.65, 95% CI 0.13-1.17), PPD (Cohen d=0.52, 95% CI 0.01-1.04), and depression (Cohen d=0.56, 95% CI 0.05-1.08), and on secondary outcome measures of overall distress (Cohen d=0.69, 95% CI 0.17-1.21), anxiety (Cohen d=0.59, 95% CI 0.07-1.11), and stress (Cohen d=0.76, 95% CI 0.23-1.28). Time-by-group interactions for proportional reductions between groups over time were only significant after treatment and at the 1-month follow-up for the primary anxiety measure (P=.006). This study was underpowered for detecting small or medium effects. Overall, clients perceived the treatment as credible, and 95% (21/22) of the clients were satisfied with the treatment content and therapist support.ConclusionsFindings from this pilot study provide preliminary support for transdiagnostic ICBT in treating PPD and PPA symptoms to improve access to psychological treatments.Trial registrationClinicalTrials.gov NCT04012580; https://clinicaltrials.gov/ct2/show/NCT04012580.

Project description:Background: Depression is a highly prevalent mental disorder, but only a fraction of those affected receive evidence-based treatments. Recently, Internet-based interventions were introduced as an efficacious and cost-effective approach. However, even though depression is a heterogenous construct, effects of treatments have mostly been determined using aggregated symptom scores. This carries the risk of concealing important effects and working mechanisms of those treatments. Methods: In this study, we analyze outcome and long-term follow-up data from the EVIDENT study, a large (N = 1,013) randomized-controlled trial comparing an Internet intervention for depression (Deprexis) with care as usual. We use Network Intervention Analysis to examine the symptom-specific effects of the intervention. Using data from intermediary and long-term assessments that have been conducted over 36 months, we intend to reveal how the treatment effects unfold sequentially and are maintained. Results: Item-level analysis showed that scale-level effects can be explained by small item-level effects on most depressive symptoms at all points of assessment. Higher scores on these items at baseline predicted overall symptom reduction throughout the whole assessment period. Network intervention analysis offered insights into potential working mechanisms: while deprexis directly affected certain symptoms of depression (e.g., worthlessness and fatigue) and certain aspects of the quality of life (e.g., overall impairment through emotional problems), other domains were affected indirectly (e.g., depressed mood and concentration as well as activity level). The configuration of direct and indirect effects replicates previous findings from another study examining the same intervention. Conclusions: Internet interventions for depression are not only effective in the short term, but also exert long-term effects. Their effects are likely to affect only a small subset of problems. Patients reporting these problems are likely to benefit more from the intervention. Future studies on online interventions should examine symptom-specific effects as they potentially reveal the potential of treatment tailoring. Clinical Trial Registration: ClinicalTrials.gov, Identifier: NCT02178631.

Dataset Information

Cost-Utility of Internet-Based Cognitive Behavioral Therapy in Unipolar Depression: A Markov Model Simulation.

Background and objective

Methods

Results

Conclusion

Publications

Cost-Utility of Internet-Based Cognitive Behavioral Therapy in Unipolar Depression: A Markov Model Simulation.

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