From the Editor
Is an ounce of prevention worth a pound of cure? As noted last week, psychiatry tends to emphasize the treatment of illness, not its prevention. But preventing illness is our ultimate goal.
Can we prevent psychotic illness?
Prevention is built on two things: we need to identify at risk individuals, and then we need to use appropriate measures to prevent the illness.
Last week. The psychosis risk calculator.
This week. Cost-effective prevention.
In this week’s Reading, we look at a paper that considers CBT to prevent psychosis in an ultra high-risk group; the paper also considers the cost-effectiveness of the intervention. So is Ben Franklin right in arguing that an ounce of prevention is worth a pound of cure? The paper doesn’t weigh in on Franklin, of course, but it does find that CBT is economically sound with an 83% likelihood of reducing the transition to psychosis and at a lower cost.
CBT and Prevention
“Four-Year Cost-effectiveness of Cognitive Behavior Therapy for Preventing First-episode Psychosis: The Dutch Early Detection Intervention Evaluation (EDIE-NL) Trial”
Helga K. Ising et al., Schizophrenia Bulletin
Online First, 15 June 2016
The economic costs of treating psychotic disorders are extremely high because (in many patients) they can last a lifetime. Therefore, advancing proactive care is important to both prevent and ameliorate long-term functional deficits. For this, identification of those most at risk of developing psychotic disorders is an essential step. The ultra-high risk (UHR) state is characterized by attenuated positive symptoms and/or a familial liability for psychotic disorders and by increased social isolation and functional decline.
In line with recent findings, in the Dutch Early Detection Intervention and Evaluation trial (EDIE-NL), we demonstrated the efficacy of cognitive behavior therapy (CBT) for UHR (CBTuhr) in preventing psychosis. Both our 18-month follow-up result and our 4-year follow-up results demonstrated a favorable effect on reducing the incidence of psychosis by ±50% compared with routine care (RC) alone.
However, it remains unknown whether investing in adjunct CBTuhr will yield savings in the longer term. This study presents a cost-effectiveness analysis (CEA) of transitions to psychosis averted over a 4-year time frame from mental health care system and societal perspectives. A secondary analysis based on quality-adjusted life year is also undertaken.
So opens a new paper by Helga K. Ising et al., just published (online first) in Schizophrenia Bulletin.
In this paper, the authors consider CBT for preventing psychosis. It’s a complicated but interesting analysis.
Here’s what they did:
· Essentially, they studied ultra high-risk individuals over a four-year period, comparing a group receiving CBT for UHR (CBTuhr) – a modified form of cognitive behavioural therapy – and routine care (RC).
· 196 individuals were included in the study; 101 in the routine care and 95 in the CBT.
· In terms of the intervention: “RC was given according to the evidence-based clinical Dutch and the National Institute for Health and Care Excellence guidelines.” “The experimental group received RC plus CBTuhr, with a maximum of 26 sessions in the first 6 months after inclusion, with the aim to prevent first-episode psychosis.”
· The inclusion criteria included: age 14–35 years; a family history of psychosis or a higher range score on the Comprehensive Assessment of At-Risk Mental States (CAARMS) and impaired social functioning.
· The exclusion criteria included: the presence of a current or past psychotic disorder, severe learning impairment, high dose antipsychotic use.
· The study considered the conversion to psychosis (the primary outcome). The authors also looked at health-related quality of life (QALY), overall functioning (SOFAS), and depression, anxiety and quality of life (BDI, SIAS, MANSA).
· Service use and costing were considered (covering everything from the cost of interventions to travel cost).
· Different statistical analyses were done, including an economic evaluation (CEA and CUA).
Here’s what they found:
· “At the 18-month follow-up measurement, 140 participants (71.4%) participated, and at 4 years, 113 patients (57.7%) had a complete follow-up assessment. Of the 83 dropouts, 9 (10.8%) had already transitioned to psychosis during the first 18 months of the study…”
· Demographically, the two groups were comparable – more female than male, single, and as likely to work/be in school as not. The mean age was 22.6 (RC) and 22.7 (CBTuhr).
· In terms of conversion: “In the CBTuhr condition, 12.6% of the participants converted to psychosis over the 4-year follow-up period. In the RC condition, 24.8% made a transition over the 4-year follow-up.” (!!)
· “The difference in QALY gains was 2.628 − 2.464 = 0.164, favoring CBTuhr. As expected, this difference was not significant…” (QALY was based on self-reported responses to several health dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.)
· “Overall, the CBTuhr condition generated lower costs (US$19,121) than the RC condition (US$24,898), representing a (nonsignificant) cost reduction of US$5,777…” What explains this difference? “The difference between CBTuhr and RC in intervention services received is partly explained by the lower psychosis conversion rate in the CBTuhr group and partly by a generally higher service use in RC.”
· The authors go on to an economic analysis, built on the findings that “the incremental costs were − US$5,777… and the incremental effect was 0.12 (a larger fraction of averted transitions to psychosis in the CBTuhr condition).” To allow for uncertainty, they used statistical analysis to simulate the incremental cost-effectiveness ratio (ICER). The figure below depicts a scatterplot of 2500 simulated ICERs on the ICER plane. They find: “a likelihood of about 83% that more transitions to psychosis are averted for fewer costs by the CBTuhr intervention relative to RC alone.”
The cost-effectiveness analysis showed that CBTuhr had an 83% probability of being more effective and less costly than RC. Similarly, the CTU shows that CBTuhr had a 75% likelihood of being more effective and less costly than RC. Various sensitivity analyses attested to the robustness of these findings. Using the Dutch WTP threshold of US$24,560 (€20,000) per QALY, the probability is 92% that the intervention is cost-effective. Also from the societal perspective, there is a substantial likelihood (73% in the primary and 78% in the secondary analysis) that CBTuhr results in more effects at lower costs. The conclusions indicate that the results of the 18 months analysis do not deteriorate when considering a period of 4 years and guided some patients through a critical period with declining transition rates.
A few thoughts:
2. This is a great paper.
3. Economic analyses should always be taken with a grain of salt – they are built on numerous assumptions and often reflect the biases of the authors. That said, the basic conclusion of this paper seems sound: by preventing psychosis in some participants, and thus avoiding the resulting higher health costs (particularly inpatient hospital costs), the intervention more than paid for itself.
4. Combine this paper with last week’s papers on the risk calculator for psychotic illness, and the potential of this work becomes even more exciting. Not that long ago, we fantasized about preventing psychotic illness; today, we seem much closer to making this a reality.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.