Economic threshold analysis of delivering a task-sharing treatment for common mental disorders at scale: the Friendship Bench, Zimbabwe

BackgroundTask-sharing treatment approaches offer a pragmatic approach to treating common mental disorders in low-income and middle-income countries (LMICs). The Friendship Bench (FB), developed in Zimbabwe with increasing adoption in other LMICs, is one example of this type of treatment model using lay health workers (LHWs) to deliver treatment.ObjectiveTo consider the level of treatment coverage required for a recent scale-up of the FB in Zimbabwe to be considered cost-effective.MethodsA modelling-based deterministic threshold analysis conducted within a ‘cost-utility’ framework using a recommended cost-effectiveness threshold.FindingsThe FB would need to treat an additional 3413 service users (10 per active LHW per year) for its scale-up to be considered cost-effective. This assumes a level of treatment effect observed under clinical trial conditions. The associated incremental cost-effectiveness ratio was $191 per year lived with disability avoided, assuming treatment coverage levels reported during 2020. The required treatment coverage for a cost-effective outcome is within the level of treatment coverage observed during 2020 and remained so even when assuming significantly compromised levels of treatment effect.ConclusionsThe economic case for a scaled-up delivery of the FB appears convincing in principle and its adoption at scale in LMIC settings should be given serious consideration.Clinical implicationsFurther evidence on the types of scale-up strategies that are likely to offer an effective and cost-effective means of sustaining required levels of treatment coverage will help focus efforts on approaches to scale-up that optimise resources invested in task-sharing programmes.

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Cost-Effectiveness of a Problem-Solving Intervention Aimed to Prevent Sickness Absence among Employees with Common Mental Disorders or Occupational Stress

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17145234 ◽

2020 ◽

Vol 17 (14) ◽

pp. 5234

Author(s):

Marijke Keus Van De Poll ◽

Gunnar Bergström ◽

Irene Jensen ◽

Lotta Nybergh ◽

Lydia Kwak ◽

...

Keyword(s):

Cost Effectiveness ◽

Problem Solving ◽

Mental Disorders ◽

Sickness Absence ◽

Common Mental Disorders ◽

Cost Benefit ◽

Cost Effective ◽

Production Loss ◽

The Cost

The cost-benefit and cost-effectiveness of a work-directed intervention implemented by the occupational health service (OHS) for employees with common mental disorders (CMD) or stress related problems at work were investigated. The economic evaluation was conducted in a two-armed clustered RCT. Employees received either a problem-solving based intervention (PSI; n = 41) or care as usual (CAU; n = 59). Both were work-directed interventions. Data regarding sickness absence and production loss at work was gathered during a one-year follow-up. Bootstrap techniques were used to conduct a Cost-Benefit Analysis (CBA) and a Cost-Effectiveness Analysis (CEA) from both an employer and societal perspective. Intervention costs were lower for PSI than CAU. Costs for long-term sickness absence were higher for CAU, whereas costs for short-term sickness absence and production loss at work were higher for PSI. Mainly due to these costs, PSI was not cost-effective from the employer’s perspective. However, PSI was cost-beneficial from a societal perspective. CEA showed that a one-day reduction of long-term sickness absence costed on average €101 for PSI, a cost that primarily was borne by the employer. PSI reduced the socio-economic burden compared to CAU and could be recommended to policy makers. However, reduced long-term sickness absence, i.e., increased work attendance, was accompanied by employees perceiving higher levels of production loss at work and thus increased the cost for employers. This partly explains why an effective intervention was not cost-effective from the employer’s perspective. Hence, additional adjustments and/or support at the workplace might be needed for reducing the loss of production at work.

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Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial

Trials ◽

10.1186/s13063-016-1191-x ◽

2016 ◽

Vol 17 (1) ◽

Cited By ~ 18

Author(s):

Charlotte Hanlon ◽

Atalay Alem ◽

Girmay Medhin ◽

Teshome Shibre ◽

Dawit A. Ejigu ◽

...

Keyword(s):

Mental Health ◽

Health Care ◽

Cost Effectiveness ◽

Mental Disorders ◽

Mental Health Care ◽

Low Income ◽

Psychiatric Nurse ◽

Task Sharing ◽

Low Income Country ◽

Randomised Controlled

Abstract Background Task sharing mental health care through integration into primary health care (PHC) is advocated as a means of narrowing the treatment gap for mental disorders in low-income countries. However, the effectiveness, acceptability, feasibility and sustainability of this service model for people with a severe mental disorder (SMD) have not been evaluated in a low-income country. Methods/Design A randomised, controlled, non-inferiority trial will be carried out in a predominantly rural area of Ethiopia. A sample of 324 people with SMD (diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder or major depressive disorder) with an ongoing need for mental health care will be recruited from 1) participants in a population-based cohort study and 2) people attending a psychiatric nurse-led out-patient clinic. The intervention is a task-sharing model of locally delivered mental health care for people with SMD integrated into PHC delivered over 18 months. Participants in the active control arm will receive the established and effective model of specialist mental health care delivered by psychiatric nurses at an out-patient clinic within a centrally located general hospital. The hypothesis is that people with SMD who receive mental health care integrated into PHC will have a non-inferior clinical outcome, defined as a mean symptom score on the Brief Psychiatric Rating Scale, expanded version, of no more than six points higher, compared to participants who receive the psychiatric nurse-led service, after 12 months. The primary outcome is change in symptom severity. Secondary outcomes are functional status, relapse, service use costs, service satisfaction, drop-out and medication adherence, nutritional status, physical health care, quality of care, medication side effects, stigma, adverse events and cost-effectiveness. Sustainability and cost-effectiveness will be further evaluated at 18 months. Randomisation will be stratified by health centre catchment area using random permuted blocks. The outcome assessors and investigators will be masked to allocation status. Discussion Evidence about the effectiveness of task sharing mental health care for people with SMD in a rural, low-income African country will inform the World Health Organisation’s mental health Gap Action Programme to scale-up mental health care globally. Trial registration NCT02308956 (ClinicalTrials.gov). Date of registration: 3 December 2014.

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Strange bedfellows: economics, happiness and mental disorder

Epidemiologia e Psichiatria Sociale ◽

10.1017/s1121189x00000488 ◽

2009 ◽

Vol 18 (3) ◽

pp. 208-213 ◽

Cited By ~ 7

Author(s):

Brian Cooper

Keyword(s):

Mental Disorders ◽

Common Mental Disorders ◽

Scale Up ◽

Cost Effective ◽

Behavioural Therapy ◽

Information Criteria ◽

Problem Definition ◽

Sources Of Information ◽

Psychological Therapies ◽

The Common

SUMMARYAim – The high economic and social costs associated with the ‘common mental disorders’, and the need to scale up appropriate care services, are now widely recognized, but responses vary from country to country. In Britain, a current government initiative to promote psychological therapy is driven both by economic pressures and by research on the factors of happiness, or life-satisfaction. This article provides a short critical review of the project. Method – A health policy analysis, with regard to problem definition; objectives; sources of information; criteria for evaluation; impact on existing services, and comparison with alternative strategies. Results – The new programme, Improving Access to Psychological Therapies (IAPT), aims to expand treatment services by training 3,600 ‘psychological therapists’ in cognitive behavioural therapy (CBT), which they will then apply in the wider community. This service, with an initial budget of £173 million, will provide treatment for depression and chronic anxiety from local centres across the country. The programme is intended to pay for itself by reducing incapacity costs. Closer examination, however, raises questions concerning the project’s theoretical basis, logistics and research methodology, and casts doubt on its advantages over alternative approaches. Conclusions – The IAPT project is ill-designed to achieve its objectives and unsuitable as a model for treatment and care of the common mental disorders in other countries. An alternative strategy, based on closer integration of community mental health and primary health care, should be tested and on previous experience seems likely to prove more cost-effective.Declaration of Interest: None.

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The WHO World Mental Health (WMH) Surveys

Die Psychiatrie ◽

10.1055/s-0038-1671923 ◽

2009 ◽

Vol 06 (01) ◽

pp. 5-9 ◽

Cited By ~ 10

Author(s):

S. Aguilar-Gaxiola ◽

J. Alonso ◽

S. Chatterji ◽

S. Lee ◽

T. B. Üstün ◽

...

Keyword(s):

Mental Health ◽

Mental Disorders ◽

Treatment Effectiveness ◽

Age Of Onset ◽

Common Mental Disorders ◽

Mental Health Policy ◽

Unmet Need ◽

Cost Effective ◽

World Mental Health ◽

Prevalence Estimates

SummaryThe paper presents an overview of the WHO World Mental Health (WMH) Survey Initiative and summarizes recent WMH results regarding the prevalence and societal costs of mental disorders. The WMH surveys are representative community surveys that were carried out in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, burden, and unmet need for treatment of common mental disorders. Results show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25th-75th percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, disruptive behavior, and substance disorders) is 18.1-36.1%. The IQR of 12-month prevalence estimates is 9.8-19.1%. Analysis of age-of-onset reports shows that many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions. Adult mental disorders are found in the WMH data to be associated with high levels of role impairment. Despite this burden, the majority of mental disorders go untreated. Although these results suggest that expansion of treatment could be cost-effective from both the employer perspective and the societal perspective, treatment effectiveness trials are needed to confirm this suspicion. The WMH results regarding impairments are being used to target several such interventions.

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Cost-effectiveness of referral for generic care or problem-solving treatment from community mental health nurses, compared with usual general practitioner care for common mental disorders

The British Journal of Psychiatry ◽

10.1192/bjp.bp.105.012435 ◽

2006 ◽

Vol 189 (1) ◽

pp. 50-59 ◽

Cited By ~ 40

Author(s):

Tony Kendrick ◽

Lucy Simons ◽

Laurence Mynors-Wallis ◽

Alastair Gray ◽

Judith Lathlean ◽

...

Keyword(s):

Mental Health ◽

Cost Effectiveness ◽

Problem Solving ◽

Community Mental Health ◽

Mental Disorders ◽

Common Mental Disorders ◽

Mental Health Nurses ◽

Nurse Care ◽

Gp Care ◽

Community Mental Health Nurses

BackgroundUK general practitioners (GPs) refer patients with common mental disorders to community mental health nurses.AimsTo determine the effectiveness and cost-effectiveness of this practice.MethodRandomised trial with three arms: usual GP care, generic mental health nurse care, and care from nurses trained in problem-solving treatment; 98 GPs in 62 practices referred 247 adult patients with new episodes of anxiety, depression and life difficulties, to 37 nurses.ResultsThere were 212 (86%) and 190 (77%) patients followed up at 8 and 26 weeks respectively. No significant differences between groups were found in effectiveness at either point. Mean differences in Clinical Interview Schedule – Revised scores at 26 weeks compared with GP care were –1.4 (95% Cl –5.5 to 2.8) for generic nurse care, and 1.1 (–2.9 to 5.1) for nurse problem-solving. Satisfaction was significantly higher in both nurse-treated groups. Mean extra costs per patient were £283 (95% Cl 154–411) for generic nurse care, and £315 (183–481) for nurse problem-solving treatment.ConclusionsGPs should not refer unselected patients with common mental disorders to specialist nurses. Problem-solving should be reserved for patients who have not responded to initial GP care.

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The Cost-effectiveness of Human Immunodeficiency Virus (HIV) Preexposure Prophylaxis and HIV Testing Strategies in High-risk Groups in India

Clinical Infectious Diseases ◽

10.1093/cid/ciz249 ◽

2019 ◽

Vol 70 (4) ◽

pp. 633-642 ◽

Cited By ~ 1

Author(s):

Pooyan Kazemian ◽

Sydney Costantini ◽

Nagalingeswaran Kumarasamy ◽

A David Paltiel ◽

Kenneth H Mayer ◽

...

Keyword(s):

Cost Effectiveness ◽

Hiv Testing ◽

Scale Up ◽

Cost Effective ◽

Status Quo ◽

Hiv Incidence ◽

Testing Strategies ◽

Preexposure Prophylaxis ◽

Immunodeficiency Virus ◽

The Cost

Abstract Background The human immunodeficiency virus (HIV) epidemic in India is concentrated among 3.1 million men who have sex with men (MSM) and 1.1 million people who inject drugs (PWID), with a mean incidence of 0.9–1.4 per 100 person-years. We examined the cost-effectiveness of both preexposure prophylaxis (PrEP) and HIV testing strategies for MSM and PWID in India. Methods We populated an HIV microsimulation model with India-specific data and projected clinical and economic outcomes of 7 strategies for MSM/PWID, including status quo; a 1-time HIV test; routine HIV testing every 3, 6, or 12 months; and PrEP with HIV testing every 3 or 6 months. We used a willingness-to-pay threshold of US$1950, the 2017 Indian per capita gross domestic product, to define cost-effectiveness. Results HIV testing alone increased life expectancy by 0.07–0.30 years in MSM; PrEP added approximately 0.90 life-years to status quo. Results were similar in PWID. PrEP with 6-month testing was cost-effective for both MSM (incremental cost-effectiveness ratio [ICER], $1000/year of life saved [YLS]) and PWID (ICER, $500/YLS). Results were most sensitive to HIV incidence. PrEP with 6-month testing would increase HIV-related expenditures by US$708 million (MSM) and US$218 million (PWID) over 5 years compared to status quo. Conclusions While the World Health Organization recommends PrEP with quarterly HIV testing, our analysis identifies PrEP with semiannual testing as the cost-effective HIV prevention strategy for Indian MSM and PWID. Since nationwide scale-up would require a substantial fiscal investment, areas of highest HIV incidence may be the appropriate initial targets for PrEP scale-up.

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Addressing the low consumption of fruit and vegetables in England: a cost-effectiveness analysis of public policies

Journal of Epidemiology & Community Health ◽

10.1136/jech-2020-214081 ◽

2020 ◽

pp. jech-2020-214081

Author(s):

Ana-Catarina Pinho-Gomes ◽

Alec Knight ◽

Julia Critchley ◽

Mark Pennington

Keyword(s):

Cost Effectiveness ◽

Low Income ◽

Healthcare Costs ◽

Cost Effective ◽

Epidemiological Studies ◽

Fruit And Vegetables ◽

Published Data ◽

Years Of Life Lost ◽

Social Marketing Campaign ◽

Low Income Households

BackgroundMost adults do not meet the recommended intake of five portions per day of fruit and vegetables (F&V) in England, but economic analyses of structural policies to change diet are sparse.MethodsUsing published data from official statistics and meta-epidemiological studies, we estimated the deaths, years-of-life lost (YLL) and the healthcare costs attributable to consumption of F&V below the recommended five portions per day by English adults. Then, we estimated the cost-effectiveness from governmental and societal perspectives of three policies: a universal 10% subsidy on F&V, a targeted 30% subsidy for low-income households and a social marketing campaign (SMC).FindingsConsumption of F&V below the recommended five portions a day accounted for 16 321 [10 091–23 516] deaths and 238 767 [170 350–311 651] YLL in England in 2017, alongside £705 951 [398 761–1 061 559] million in healthcare costs. All policies would increase consumption and reduce the disease burden attributable to low intake of F&V. From a societal perspective, the incremental cost-effectiveness ratios were £22 891 [22 300–25 079], £16 860 [15 589–19 763] and £25 683 [25 237–28 671] per life-year saved for the universal subsidy, targeted subsidy and SMC, respectively. At a threshold of £20 000 per life-year saved, the likelihood that the universal subsidy, the targeted subsidy and the SMC were cost-effective was 84%, 19% and 5%, respectively. The targeted subsidy would additionally reduce inequalities.ConclusionsLow intake of F&V represents a heavy health and care burden in England. All dietary policies can improve consumption of F&V, but only a targeted subsidy to low-income households would most likely be cost-effective.

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A Computationally Efficient Method for Probabilistic Parameter Threshold Analysis for Health Economic Evaluations

Medical Decision Making ◽

10.1177/0272989x20937253 ◽

2020 ◽

Vol 40 (5) ◽

pp. 669-679

Author(s):

Zoë Pieters ◽

Mark Strong ◽

Virginia E. Pitzer ◽

Philippe Beutels ◽

Joke Bilcke

Keyword(s):

Monte Carlo ◽

Cost Effectiveness ◽

Cost Effective ◽

Routine Vaccination ◽

Threshold Analysis ◽

Threshold Values ◽

Threshold Probability ◽

Monte Carlo Approach ◽

Effectiveness Model ◽

The Cost

Background. Threshold analysis is used to determine the threshold value of an input parameter at which a health care strategy becomes cost-effective. Typically, it is performed in a deterministic manner, in which inputs are varied one at a time while the remaining inputs are each fixed at their mean value. This approach will result in incorrect threshold values if the cost-effectiveness model is nonlinear or if inputs are correlated. Objective. To propose a probabilistic method for performing threshold analysis, which accounts for the joint uncertainty in all input parameters and makes no assumption about the linearity of the cost-effectiveness model. Methods. Three methods are compared: 1) deterministic threshold analysis (DTA); 2) a 2-level Monte Carlo approach, which is considered the gold standard; and 3) a regression-based method using a generalized additive model (GAM), which identifies threshold values directly from a probabilistic sensitivity analysis sample. Results. We applied the 3 methods to estimate the minimum probability of hospitalization for typhoid fever at which 3 different vaccination strategies become cost-effective in Uganda. The threshold probability of hospitalization at which routine vaccination at 9 months with catchup campaign to 5 years becomes cost-effective is estimated to be 0.060 and 0.061 (95% confidence interval [CI], 0.058–0.064), respectively, for 2-level and GAM. According to DTA, routine vaccination at 9 months with catchup campaign to 5 years would never become cost-effective. The threshold probability at which routine vaccination at 9 months with catchup campaign to 15 years becomes cost-effective is estimated to be 0.092 (DTA), 0.074 (2-level), and 0.072 (95% CI, 0.069–0.075) (GAM). GAM is 430 times faster than the 2-level approach. Conclusions. When the cost-effectiveness model is nonlinear, GAM provides similar threshold values to the 2-level Monte Carlo approach and is computationally more efficient. DTA provides incorrect results and should not be used.

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Poverty, psychological disorder and disability in primary care attenders in Goa, India

The British Journal of Psychiatry ◽

10.1192/bjp.172.6.533 ◽

1998 ◽

Vol 172 (6) ◽

pp. 533-536 ◽

Cited By ~ 73

Author(s):

Vikram Patel ◽

Jerson Pereira ◽

Livia Countinho ◽

Romaldina Fernandes ◽

John Fernandes ◽

...

Keyword(s):

Mental Disorders ◽

Mental Disorder ◽

Low Income ◽

Common Mental Disorders ◽

Common Mental Disorder ◽

Female Gender ◽

Psychological Disorder ◽

Low Income Countries ◽

Health Clinic ◽

Primary Health

BackgroundThis study examined the association of common mental disorders in primary health clinic attenders with indicators of poverty and disability in Goa, India.MethodAdult attenders (n=303) in two primary health clinics were recruited.ResultsThere were 141 (46.5%) cases of common mental disorder. The following were associated with common mental disorder: female gender; inability to buy food due to lack of money; and being in debt. Cases scored significantly higher on all measures of disability. Primary health clinic staff recognised a third of the morbidity but used multiple oral drugs, injectable vitamins and benzodiazepines to treat common mental disorders.ConclusionsPoverty is closely associated with common mental disorder which in turn is associated with deprivation and despair. Primary mental health care priorities in low-income countries need to shift from psychotic disorders which often need specialist care to common mental disorders. Health policy and development agencies need to acknowledge the intimate association of female gender and poverty with these disorders.

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Cost-effectiveness analysis of a community paramedicine programme for low-income seniors living in subsidised housing: the community paramedicine at clinic programme (CP@clinic)

BMJ Open ◽

10.1136/bmjopen-2020-037386 ◽

2020 ◽

Vol 10 (10) ◽

pp. e037386

Author(s):

Gina Agarwal ◽

Melissa Pirrie ◽

Ricardo Angeles ◽

Francine Marzanek ◽

Lehana Thabane ◽

...

Keyword(s):

Cost Effectiveness ◽

Usual Care ◽

Low Income ◽

Scale Up ◽

Intervention Group ◽

Cost Utility ◽

Computer Assisted ◽

Programme Cost ◽

Community Paramedicine ◽

Life Years

ObjectivesTo evaluate the cost-effectiveness of the Community Paramedicine at Clinic (CP@clinic) programme compared with usual care in seniors residing in subsidised housing.DesignA cost–utility analysis was conducted within a large pragmatic cluster randomised controlled trial (RCT). Subsidised housing buildings were matched by sociodemographics and location (rural/urban), and allocated to intervention (CP@clinic for 1 year) or control (usual care) via computer-assisted paired randomisation.SettingThirty-two subsidised seniors’ housing buildings in Ontario.ParticipantsBuilding residents 55 years and older.InterventionCP@clinic is a weekly community paramedic-led, chronic disease prevention and health promotion programme in the building common areas. CP@clinic is free to residents and includes risk assessments, referrals to resources, and reports back to family physicians.Outcome measuresQuality-adjusted life years (QALYs) gained, measured with EQ-5D-3L. QALYs were estimated using area-under-the curve over the 1-year intervention, controlling for preintervention utility scores and building pairings. Programme cost data were collected before and during implementation. Costs associated with emergency medical services (EMS) use were estimated. An incremental cost effectiveness ratio (ICER) based on incremental costs and health outcomes between groups was calculated. Probabilistic sensitivity analysis using bootstrapping was performed.ResultsThe RCT included 1461 residents; 146 and 125 seniors completed the EQ-5D-3L in intervention and control buildings, respectively. There was a significant adjusted mean QALY gain of 0.03 (95% CI 0.01 to 0.05) for the intervention group. Total programme cost for implementing in five communities was $C128 462 and the reduction in EMS calls avoided an estimated $C256 583. The ICER was $C2933/QALY (bootstrapped mean ICER with Fieller’s 95% CI was $4850 ($2246 to $12 396)) but could be even more cost effective after accounting for the EMS call reduction.ConclusionThe CP@clinic ICER was well below the commonly used Canadian cost–utility threshold of $C50 000. CP@clinic scale-up across subsidised housing is feasible and could result in better health-related quality-of-life and reduced EMS use in low-income seniors.Trial registration numberClinicaltrials.gov, NCT02152891.

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