Cost-utility and cost-effectiveness of individual placement support and cognitive remediation in people with severe mental illness: Results from a randomized clinical trial.
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ABSTRACT: Background
Administrators and policymakers are increasingly interested in individual placement and support (IPS) as a way of helping people with severe mental illness (SMI) obtain employment or education. It is thus important to investigate the cost-effectiveness to secure that resources are being used properly.Methods
In a randomized clinical trial, 720 people diagnosed with SMI were allocated into three groups; (a) IPS, (b) IPS supplemented with cognitive remediation a social skills training (IPSE), and (c) Service as usual (SAU). Health care costs, municipal social care costs, and labor market service costs were extracted from nationwide registers and combined with data on use of IPS services. Cost-utility and cost-effectiveness analyses were conducted with two primary outcomes: quality-adjusted life years (QALY) and hours in employment. Incremental cost-effectiveness ratios (ICER) were computed for both QALY, using participant's responses to the EQ-5D questionnaire, and for hours in employment.Results
Both IPS and IPSE were less costly, and more effective than SAU. Overall, there was a statistically significant cost difference of €9,543 when comparing IPS with SAU and €7,288 when comparing IPSE with SAU. ICER's did generally not render statistically significant results. However, there was a tendency toward the IPS and IPSE interventions being dominant, that is, cheaper with greater effect in health-related quality of life and hours in employment or education compared to usual care.Conclusion
Individual placement support with and without a supplement of cognitive remediation tends to be cost saving and more effective compared to SAU.
SUBMITTER: Christensen TN
PROVIDER: S-EPMC8057485 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Importance:Individual placement and support (IPS) seems to be an effective vocational intervention for people with severe mental illness, but its effects have not yet been shown in the Danish welfare model. Also, effects may be enhanced by adding cognitive remediation and work-focused social skills training (IPS with enhancements [IPSE]). Objectives:To investigate the effects of IPS vs IPSE vs service as usual (SAU) on a population of individuals with severe mental illness in Denmark. Design, Setting, and Participants:This was an investigator-initiated, 3-group, parallel, assessor-blinded randomized clinical trial that used early-intervention teams or community mental health services in 3 Danish cities to recruit participants with severe mental illness. Participants were randomly assigned to receive IPS, IPSE, or SAU from November 2012 to February 2016, and follow-up continued until August 2017. Interventions:Participants allocated to the IPS intervention received vocational support per the principles of the IPS model. Participants in the IPSE arm received cognitive remediation and social skills training in addition to IPS. The group receiving SAU received vocational rehabilitation at the Danish job centers. Main Outcomes and Measures:The primary outcome was the number of hours in competitive employment or education during the 18-month follow-up. Secondary outcomes included intergroup differences in employment or education at any point during follow-up; time to employment or education; and cognitive and social functioning, self-esteem, and self-efficacy. Results:Of the 720 included participants (mean [SD] age, 32.8 [9.9] years; 276 [38.3%] women), 243 received IPS, 238 received IPSE, and 239 received SAU. Most participants (551 [76.5%]) were diagnosed with a schizophrenia spectrum disorder. During the 18-month follow-up, the IPSE group worked or studied a mean (SD) of 488.1 (735.6) hours, compared with 340.8 (573.8) hours in the group receiving SAU (success-rate difference [SRD], 0.151 [95% CI, 0.01-0.295]; P?=?.016). The mean (SD) in the IPS group was 411 (656.9) (SRD, 0.127 [95% CI, -0.017 to 0.276]; P?=?.004). There was no difference between IPS and IPSE in any vocational outcomes, and the 3 groups showed no differences in any nonvocational outcomes, except that the IPS and IPSE groups were more satisfied with the services received than the group receiving SAU (IPS vs SAU: SRD, 0.310 [95% CI, 0.167-0.445]); IPSE vs SAU: SRD, 0.341 [95% CI, 0.187-0.478]). Conclusions and Relevance:Compared with SAU, IPS and IPSE seem to be viable routes to increase employment and education rates in people with severe mental illness in Denmark, but no additional effects were observed by enhancing IPS. Trial Registration:ClinicalTrials.gov identifier: NCT01722344.
| S-EPMC6727676 | biostudies-literature
Project description:BACKGROUND:Individual Placement and Support (IPS) is an evidence-based approach to help people with severe mental illness achieve competitive employment. This article provides insight into an organizational and a financial implementation strategy for IPS in the Netherlands by exploring the perceived facilitators and barriers among participating stakeholders. The goal of this multifaceted strategy was to improve IPS implementation by improving the collaboration between all organizations involved, and realising secured IPS funding with a 'pay for performance' element. METHODS:A qualitative, explorative study among practitioners (n?=?8) and decision makers (n?=?7) in mental health care and vocational rehabilitation was performed using semi-structured interviews to collect rich information about the possible facilitators and barriers with regard to the organizational and financial implementation strategy for IPS. RESULTS:Important perceived facilitators were the key principles of the IPS model, regular meetings of stakeholders in mental health care and vocational rehabilitation, stakeholders' experienced ownership of IPS and collaboration, the mandate and influence of the decision makers involved and secured IPS funding. Important perceived barriers included the experienced rigidity of the IPS model fidelity scale and lack of independent fidelity reviewers, the temporary and fragmented character of the secured funding, lack of communication between decision makers and practitioners and negative attitudes and beliefs among mental health clinicians. Changes in legislation were experienced as a facilitator as well as a barrier. CONCLUSIONS:The results of this study suggest that the collaboration and IPS funding were experienced as improved by applying an organizational and a financial implementation strategy. However, considerable effort is still necessary to overcome the remaining barriers identified and to make the implementation of IPS a success in practice.
| S-EPMC5968490 | biostudies-literature
Project description:BackgroundMany people with moderate to severe mental illness have a desire to obtain ordinary employment. To aid further development of health and social services for this group, the aim of this study was to examine candidate modifiable and prognostic markers of employment, and moderating effects of group allocation in a clinical trial.MethodThe sample consists of 327 patients in treatment for mental illness, randomized to Individual Placement and Support (IPS) or treatment as usual (TAU) as part of a clinical trial. Psychosocial and demographic baseline characteristics were included as predictors in log binary regression analyses with employment 18 months after inclusion as the outcome, and group allocation as the moderator (IPS or TAU).ResultsDirective emotional support and non-directive instrumental support seemed to positively predict employment, but effects were small. Involuntary hospitalization seemed to be a strong negative predictor of employment. Group allocation did not moderate any main effects.ConclusionInterpretation of the findings suggest that attention should be given to certain aspects of health and social services provided to this target group, and in particular the effect of receiving appropriate types of social support. The findings are novel because social support and involuntary hospitalization do not seem to have been included in previous predictor studies. The results from this study identify new topics for research on employment outcomes for this population.
| S-EPMC8191162 | biostudies-literature
Project description:ObjectivesTo determine the cost-effectiveness of two bespoke severe mental illness (SMI)-specific risk algorithms compared with standard risk algorithms for primary cardiovascular disease (CVD) prevention in those with SMI.SettingPrimary care setting in the UK. The analysis was from the National Health Service perspective.Participants1000 individuals with SMI from The Health Improvement Network Database, aged 30-74 years and without existing CVD, populated the model.InterventionsFour cardiovascular risk algorithms were assessed: (1) general population lipid, (2) general population body mass index (BMI), (3) SMI-specific lipid and (4) SMI-specific BMI, compared against no algorithm. At baseline, each cardiovascular risk algorithm was applied and those considered high risk (> 10%) were assumed to be prescribed statin therapy while others received usual care.Primary and secondary outcome measuresQuality-adjusted life years (QALYs) and costs were accrued for each algorithm including no algorithm, and cost-effectiveness was calculated using the net monetary benefit (NMB) approach. Deterministic and probabilistic sensitivity analyses were performed to test assumptions made and uncertainty around parameter estimates.ResultsThe SMI-specific BMI algorithm had the highest NMB resulting in 15 additional QALYs and a cost saving of approximately £53 000 per 1000 patients with SMI over 10 years, followed by the general population lipid algorithm (13 additional QALYs and a cost saving of £46 000).ConclusionsThe general population lipid and SMI-specific BMI algorithms performed equally well. The ease and acceptability of use of an SMI-specific BMI algorithm (blood tests not required) makes it an attractive algorithm to implement in clinical settings.
| S-EPMC5588956 | biostudies-literature
Project description:As Individual Placement and Support (IPS) has become the international standard for vocational rehabilitation of adults with serious mental illness, researchers must consider the relationship between IPS and local environments. This meta-analysis used mixed-effects meta-regressions to assess the impact of site-level moderators on the likelihood that IPS recipients, compared with recipients of alternative vocational services, achieved competitive employment. Potential moderators included change in gross domestic product (GDP), local unemployment and unionization rates, and indices describing employment protection regulations, level of disability benefits compensation, and efforts to integrate people with disabilities into the workforce. Regulatory moderators represent facilitators and barriers to employment that may reinforce or detract from the effectiveness of IPS. Across 30 sites drawn from 21 randomized controlled trials in 12 countries (33% in the United States), IPS recipients were 2.31 (95% CI 1.99-2.69) times more likely to find competitive employment than recipients of alternative vocational rehabilitation services. The significant competitive-employment rate advantage of IPS over control services increased in the presence of weaker employment protection legislation and integration efforts, and less generous disability benefits. Policy makers should recognize and account for the fact that labor and disability regulations can create an arrangement of incentives that reduces the relative efficacy of supported employment.
| S-EPMC5768052 | biostudies-literature
Project description:BackgroundPeer support provides the opportunity for peers with experiential knowledge of a mental illness to give emotional, appraisal and informational assistance to current service users, and is becoming an important recovery-oriented approach in healthcare for people with mental illness.ObjectivesTo assess the effects of peer-support interventions for people with schizophrenia or other serious mental disorders, compared to standard care or other supportive or psychosocial interventions not from peers.Search methodsWe searched the Cochrane Schizophrenia Group's Study-Based Register of Trials on 27 July 2016 and 4 July 2017. There were no limitations regarding language, date, document type or publication status.Selection criteriaWe selected all randomised controlled clinical studies involving people diagnosed with schizophrenia or other related serious mental illness that compared peer support to standard care or other psychosocial interventions and that did not involve 'peer' individual/group(s). We included studies that met our inclusion criteria and reported useable data. Our primary outcomes were service use and global state (relapse).Data collection and analysisThe authors of this review complied with the Cochrane recommended standard of conduct for data screening and collection. Two review authors independently screened the studies, extracted data and assessed the risk of bias of the included studies. Any disagreement was resolved by discussion until the authors reached a consensus. We calculated the risk ratio (RR) and 95% confidence interval (CI) for binary data, and the mean difference and its 95% CI for continuous data. We used a random-effects model for analyses. We assessed the quality of evidence and created a 'Summary of findings' table using the GRADE approach.Main resultsThis review included 13 studies with 2479 participants. All included studies compared peer support in addition to standard care with standard care alone. We had significant concern regarding risk of bias of included studies as over half had an unclear risk of bias for the majority of the risk domains (i.e. random sequence generation, allocation concealment, blinding, attrition and selective reporting). Additional concerns regarding blinding of participants and outcome assessment, attrition and selective reporting were especially serious, as about a quarter of the included studies were at high risk of bias for these domains.All included studies provided useable data for analyses but only two trials provided useable data for two of our main outcomes of interest, and there were no data for one of our primary outcomes, relapse. Peer support appeared to have little or no effect on hospital admission at medium term (RR 0.44, 95% CI 0.11 to 1.75; participants = 19; studies = 1, very low-quality evidence) or all-cause death in the long term (RR 1.52, 95% CI 0.43 to 5.31; participants = 555; studies = 1, very low-quality evidence). There were no useable data for our other prespecified important outcomes: days in hospital, clinically important change in global state (improvement), clinically important change in quality of life for peer supporter and service user, or increased cost to society.One trial compared peer support with clinician-led support but did not report any useable data for the above main outcomes.Authors' conclusionsCurrently, very limited data are available for the effects of peer support for people with schizophrenia. The risk of bias within trials is of concern and we were unable to use the majority of data reported in the included trials. In addition, the few that were available, were of very low quality. The current body of evidence is insufficient to either refute or support the use of peer-support interventions for people with schizophrenia and other mental illness.
| S-EPMC6448529 | biostudies-literature
Project description:BACKGROUND:People with severe mental illness (SMI) must receive early interventions to prevent mental health deterioration or relapse. Telecommunications and other technologies are increasingly being used to assist in health care delivery using "telehealth," which includes telephones and mobile phones, computers, remote sensors, the internet, and other devices, to provide immediate real-time information to service users to improve the management of chronic health conditions. Some initial findings have suggested that technology could improve the quality of life of people with SMI. OBJECTIVE:In this systematic review, we aimed to identify the various uses and efficacy of telehealth technology for SMI. METHODS:We systematically searched electronic databases from inception to March 2016 (MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, Health Technology Assessment, CINAHL Plus, and NHS Economic Evaluations Database) to identify randomized controlled trials evaluating telehealth for adults with SMI published in English. Additional literature was identified through searching reference lists of key articles. The articles meeting the inclusion criteria were systematically reviewed and assessed for quality and risk of bias. RESULTS:Our search identified 31 articles describing 29 trials as eligible for the review. The included studies evaluated the use of computers to deliver cognitive rehabilitation (15 trials), patient education (3 trials), and Web-based self-management interventions (2 trials) and to support consultations (1 trial). Virtual reality was used to simulate work and social situations (2 trials) and to deliver cognitive training (1 trial). Telephones were used to prompt service users to take medications (3 trials) and to report symptoms to their health care team (1 trial). Remote sensors were used to monitor medication use (1 trial). Telephone support was found effective in improving medication adherence and reducing the severity of symptoms and inpatient days. Computer-assisted cognitive rehabilitation was effective in improving cognitive function. The impact of telehealth on other outcomes was inconsistent. The results of this review should be taken in the context of varied quality in study design, with only 5 studies demonstrating a low risk of bias. CONCLUSIONS:A growing variety of telehealth technologies are being used to support the management of SMI. Specific technology types have been found to be effective for some outcomes (eg, telephone and remote medication monitoring for adherence to treatment), while other types of telehealth technologies (eg, delivery of patient education using computers) had no benefit over traditional nurse-based methods and were less acceptable to patients. Further research is warranted to establish the full potential benefits of telehealth for improving the quality of life in people with SMI, acceptability from the service user perspective, and cost-effectiveness. The findings of this review are limited by the poor quality of many of the studies reviewed.
| S-EPMC6314801 | biostudies-other
Project description:BACKGROUND:Unemployment is highly prevalent in populations with alcohol and drug dependence and the employment support offered in addiction-treatment programmes is ineffective. Individual Placement and Support (IPS) is an evidence-based intervention for competitive employment. IPS has been extensively studied in severe mental illness and physical disabilities, but there have been no formal randomised controlled trials (RCTs) in alcohol and drug dependence. The Individual Placement and Support for Alcohol and Drug Dependence (IPS-AD) study should determine whether IPS for patients with alcohol use disorder (AUD), opioid use disorder (OUD) and other drug use disorder is effective. DESIGN/METHODS:The IPS-AD study is a seven-site, pragmatic, two-arm, parallel-group, superiority RCT. IPS-AD includes a realist process evaluation. Eligible patients (adult, unemployed or economically inactive for at least 6?months and wishing to obtain open job market employment and enrolled in ongoing community treatment-as-usual (TAU; the control condition) in England for AUD, OUD and other drug use disorders) will be randomised (1:1) to receive TAU and any standard employment support, or TAU plus IPS (the experimental condition) for 9 months with up to 4 months of in-work support. The primary outcome measure will be competitive employment status (at least 1 day (7?h)) during an 18-month follow-up, determined by patient-level, trial-data-linkage with national tax and state benefit databases. From meta-analysis, an 18% target difference on this measure of vocational effectiveness (for the experimental intervention) and a two-sided 5% level of statistical significance, will require a minimum target sample of 832 participants to achieve 90% power for a pre-registered, mixed-effects, multi-variable logistic regression model. A maximum-likelihood multiple-imputation approach will manage missing outcome data. IPS-AD has six vocational secondary outcome measures during the 18-month follow-up: (1) total time in competitive employment (and corresponding National Insurance contributions and tax paid); (2) time from randomisation to first competitive employment; (3) number of competitive job appointments; (4) job tenure (length of longest held competitive employment); (5) sustained employment (tenure in a single appointment for at least 13?weeks); and (6) job search self-efficacy. A primary cost-benefit analysis and a secondary cost-effectiveness analysis will be done using the primary outcome and secondary vocational outcomes, respectively and will include addiction treatment and social and health outcomes and their associated reference costs. The process evaluation will address IPS implementation and delivery. DISCUSSION:The IPS-AD study is the first large-scale, multi-site, definitive, superiority RCT of IPS for people with alcohol and drug dependence. Findings from the study will have substantial implications for service delivery. TRIAL REGISTRATION:ISRCTN Registry, ID: ISRCTN24159790. Registered on 1 February 2018.
| S-EPMC7014654 | biostudies-literature
Project description:BACKGROUND:Peer-delivered services potentially provide broad, multifaceted benefits for persons suffering severe mental illness. Most studies to date have been conducted in countries with well-developed outpatient mental health systems. The objective of this study was to examine the feasibility for developing a community-based peer service in China. METHODS:Thirteen peer service providers and 54 consumers were recruited from four communities in Beijing. We initiated the program in two communities, followed by another two in order to verify and add to our understanding of potential scalable feasibility. Semi-structured face-to-face interviews were conducted 12?month after initiation at each site to measure satisfaction and perceived benefits from perspectives of peer service providers, and consumers and their caregivers. RESULTS:Key stakeholders reported that peer support services were satisfying and beneficial. Eleven of 13 peer service providers were willing to continue in their roles. Ten, 8, and 7 of them perceived improvements in working skills, social communication skills, and mood, respectively. Among consumers, 39 of 54 were satisfied with peer services. Improvements in mood, social communication skills, illness knowledge, and illness stability were detected among 23, 18, 13, and 13 consumers, respectively. For caregivers, 31 of 32 expressed a positive view regarding peer services. Caregivers reported improvement in their own mood, confidence in recovery of their family members, and reduction in caretaker burdens. CONCLUSIONS:The findings highlight that peer-delivered services have promise in China for benefiting persons with severe mental illness and their family caregivers, as well as the peer service providers themselves.
| S-EPMC6854628 | biostudies-literature
Project description:This study examined the cost-effectiveness of a cognitive-behavioral therapy (CBT) intervention for posttraumatic stress disorder (PTSD) that is tailored for adults with a co-occurring severe mental illness.Data were from a randomized trial involving 183 adult clients of two outpatient clinics and three partial hospitalization programs. All had a severe mental illness diagnosis (major mood disorder, schizophrenia, or schizoaffective disorder) and severe PTSD. Participants were randomly assigned to the tailored 12- to 16-session CBT intervention for PTSD (CBT-P) or a three-session breathing retraining and psychoeducation intervention (BRF). Cost estimates included intervention costs for training, supervision, fidelity assessment, personnel, and overhead and related mental health care costs for outpatient, inpatient, and emergency department services and for medications. The incremental cost-effectiveness ratio comparing CBT-P with BRF measured the added cost or savings per remission from PTSD at 12 months postintervention. Generalized linear models were used to estimate intervention effects on annual mental health care costs and the likelihood of a remission from PTSD. Ten thousand bootstrap replications were used to assess uncertainty.Annual mean mental health care costs were $25,539 per client (in 2010 dollars) for BRF participants and $29,530 per client for CBT-P participants, a nonsignificant difference. The mean incremental cost-effectiveness ratio was $36,893 per additional PTSD remission yielded by CBT-P compared with BRF (95% confidence interval=-$33,523 to $158,914). Remissions were associated with improvements in quality of life and functioning.An effective CBT intervention tailored for adults with severe mental illness and PTSD was not found to be more cost-effective than a brief three-session intervention.
| S-EPMC5711573 | biostudies-literature