Cost-effectiveness of a stepped care intervention to prevent depression and anxiety in late life: Randomised trial

Department of General Practice, Institute for Research in Extramural Medicine, VU Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
The British journal of psychiatry: the journal of mental science (Impact Factor: 7.99). 04/2010; 196(4):319-25. DOI: 10.1192/bjp.bp.109.069617
Source: PubMed


There is an urgent need for the development of cost-effective preventive strategies to reduce the onset of mental disorders.
To establish the cost-effectiveness of a stepped care preventive intervention for depression and anxiety disorders in older people at high risk of these conditions, compared with routine primary care.
An economic evaluation was conducted alongside a pragmatic randomised controlled trial (ISRCTN26474556). Consenting individuals presenting with subthreshold levels of depressive or anxiety symptoms were randomly assigned to a preventive stepped care programme (n = 86) or to routine primary care (n = 84).
The intervention was successful in halving the incidence rate of depression and anxiety at euro563 ( pound412) per recipient and euro4367 ( pound3196) per disorder-free year gained, compared with routine primary care. The latter would represent good value for money if the willingness to pay for a disorder-free year is at least euro5000.
The prevention programme generated depression- and anxiety-free survival years in the older population at affordable cost.

Download full-text


Available from: Harm Van Marwijk, Jan 20, 2014
21 Reads
  • Source
    • "Clinical trials examining people with various types of subthreshold anxiety confirm this benefit. They found preliminary evidence for the benefits of herbal medicine (lavender) compared to placebo on self-report measures for anxiety [69] and for a self-help intervention program compared to usual care, which reduced the incidence of new full-syndrome anxiety diagnoses by 50% and therefore saved health-care costs each disorder-free year [70,71]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background To review the prevalence and impact of generalized anxiety disorder (GAD) below the diagnostic threshold and explore its treatment needs in times of scarce healthcare resources. Methods A systematic literature search was conducted until January 2013 using PUBMED/MEDLINE, PSYCINFO, EMBASE and reference lists to identify epidemiological studies of subthreshold GAD, i.e. GAD symptoms that do not reach the current thresholds of DSM-III-R, DSM-IV or ICD-10. Quality of all included studies was assessed and median prevalences of subthreshold GAD were calculated for different subpopulations. Results Inclusion criteria led to 15 high-quality and 3 low-quality epidemiological studies with a total of 48,214 participants being reviewed. Whilst GAD proved to be a common mental health disorder, the prevalence for subthreshold GAD was twice that for the full syndrome. Subthreshold GAD is typically persistent, causing considerably more suffering and impairment in psychosocial and work functioning, benzodiazepine and primary health care use, than in non-anxious individuals. Subthreshold GAD can also increase the risk of onset and worsen the course of a range of comorbid mental health, pain and somatic disorders; further increasing costs. Results are robust against bias due to low study quality. Conclusions Subthreshold GAD is a common, recurrent and impairing disease with verifiable morbidity that claims significant healthcare resources. As such, it should receive additional research and clinical attention.
    BMC Psychiatry 05/2014; 14(1):128. DOI:10.1186/1471-244X-14-128 · 2.21 Impact Factor
  • Source
    • "Notable exceptions exist: randomised-controlled trials have shown that improvements in depressive symptoms [58-60] and in social activity [61] are achievable in primary practice settings. A stepped care approach in primary care was also shown to be effective to prevent late life depression [62]. Bogner et al. [58] and Katon et al. [59] showed that in patients with depression and a chronic physical condition, outcomes of both can be improved by integrated and collaborative care, where physicians receive guideline-based recommendations for treatment. "
    [Show abstract] [Hide abstract]
    ABSTRACT: It is not well established how psychosocial factors like social support and depression affect health-related quality of life in multimorbid and elderly patients. We investigated whether depressive mood mediates the influence of social support on health-related quality of life. Cross-sectional data of 3,189 multimorbid patients from the baseline assessment of the German MultiCare cohort study were used. Mediation was tested using the approach described by Baron and Kenny based on multiple linear regression, and controlling for socioeconomic variables and burden of multimorbidity. Mediation analyses confirmed that depressive mood mediates the influence of social support on health-related quality of life (Sobel's p < 0.001). Multiple linear regression showed that the influence of depressive mood (beta = -0.341, p < 0.01) on health-related quality of life is greater than the influence of multimorbidity (beta = -0.234, p < 0.01). Social support influences health-related quality of life, but this association is strongly mediated by depressive mood. Depression should be taken into consideration in research on multimorbidity, and clinicians should be aware of its importance when caring for multimorbid patients.Trial register: ISRCTN89818205.
    BMC Family Practice 04/2014; 15(1):62. DOI:10.1186/1471-2296-15-62 · 1.67 Impact Factor
  • Source
    • "More recently, stepped-care approaches for depression have been found to be feasible in primary care for diverse patient populations. Stepped-care approaches can both generate well-being and reduce healthcare costs [4-10]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Since 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC) was initiated in the Netherlands. Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT). The introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring), were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method), and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT constructs 'coherence' and 'cognitive participation' appeared to be crucial drivers in the initial stage of the process. Stepped care for depression is received positively in primary care. While it is difficult for the implementation of a full stepped-care approach to occur within a short time frame, clinicians can make progress towards achieving a stepped-care approach, particularly within the context of a QIC. Creating a shared understanding within multidisciplinary teams of what constitutes depression, reaching a consensus about the content of depression care, and the division of tasks are important when addressing the implementation process.
    Implementation Science 01/2012; 7(1):8. DOI:10.1186/1748-5908-7-8 · 4.12 Impact Factor
Show more