Cost-effectiveness of Preventive Interventions for Depressive Disorders

An Overview

Cathrine Mihalopoulos; Theo Vos

Disclosures

Expert Rev Pharmacoeconomics Outcomes Res. 2013;13(2):237-242. 

In This Article

Abstract and Introduction

Abstract

The last 7 years have seen a growing number of cost–effectiveness studies demonstrating that screening people for signs of depression and the subsequent provision of psychological therapy to prevent the onset of depressive disorder is a cost-effective intervention. Many of the studies have expressed outcomes generically, either as quality-adjusted life-years or disability-adjusted life-years, and reported results well below conventional thresholds of 'value for money.' However, such interventions are still not routinely delivered in many healthcare systems, suggesting a 'translational' gap between evidence and practice. Future research needs to better integrate comprehensive economic evaluation indices into study designs, such as broad assessment of costs and impacts, including non-health impacts, to gain an accurate insight into the broader economic benefits of such interventions. Furthermore, a focus on interventions aimed at children and adolescents, which can demonstrate impact into adulthood, are likely to be highly favourable, both clinically and economically.

Introduction

Depression is common, disabling and costly. A study of international estimates of the point prevalence of depression in adult populations reported a global pooled estimate of 4.7% (females: 5.9%; males: 3.8%).[1] In 2010, depressive disorders were responsible for 3% of the global burden of disease[2] and for 10% of the nonfatal burden.[3] The development of depression in childhood or adolescence (as well as adulthood) can have detrimental effects on school and work performance, as well as substantially increasing the risk of suicide.[4] Similarly, the impacts of depression in adulthood extend beyond the individual to families, carers and the broader society. A systematic review of internationally published depression cost-of-illness studies found that depression is associated with high annual health sector and productivity costs due to high rates of absenteeism and work drop-outs.[5] Current treatment of depression in Australia averts 13–16% of the disease burden and even if all cases of depression were treated using evidence-based treatments, only 24–52% of the disease burden could be averted.[6,7]

Unsurprisingly, the prevention of depression is of growing interest to researchers and policy-makers. There is a growing literature that suggests that depression can be prevented in adults and children.[8–13] The most effective interventions reported in the literature to date have a screening and treatment component. People are screened for subsyndromal depression, which is the existence of some depressive symptoms but an insufficient number to warrant a full diagnosis of a major depressive disorder (MDD), and subsequently given psychotherapy (usually cognitive–behavioral) to prevent the onset of full MDD. These types of interventions have been termed 'indicated prevention' using the nomenclature of Mrazek and Haggerty.[14] Indicated interventions are targeted at people with existing signs or symptoms of the disorder, selective interventions are targeted at people considered to be in 'high-risk' categories (such as the children of depressed mothers or people with serious physical health problems) and universal interventions target the whole population. Existing reviews of these interventions find that indicated interventions in particular can be effective in reducing the onset of MDD by 25–50%.[9,13] In a recent review, Muñoz et al. discussed 29 trials of preventive interventions for mental disorders.[13] While universal interventions have been evaluated,[15–17] these have demonstrated less compelling evidence of effects compared with indicated and selective interventions. However, whether such interventions provide good value for finite health resources (or are cost effective) remains unknown.

The aim of the current paper is to provide a descriptive overview of the existing economic evaluations of preventive interventions for depressive disorder. The papers discussed in this overview have been sourced from the literature using the same search strategy as that described in Mihalopoulos[18] and Mihalopoulos et al.,[19] but updated to include any recently published papers (published beyond April 2010 up until mid-2012). Briefly, the strategy included a search of Medline, Psychinfo and Econlit using the search terms 'prevent' and 'depress', and 'cost' or 'economic'. Studies were included if they met the definition of a full economic evaluation, defined as a comparative evaluation where both the costs and consequences of alternatives courses of action are included.[20] Only studies which have evaluated the presence or absence of diagnosed MDD at follow-up have been included in this overview.

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