Brief CBT Lifesaving, Cost-Effective for Suicidal Crises

Megan Brooks

December 04, 2019

Brief cognitive-behavioral therapy (CBT) is likely a cost-saving intervention for suicidal active-duty Army soldiers, a new economic analysis of the treatment suggests.

"Averting suicide attempts has the potential to reduce a variety of healthcare and other costs," first author Samantha Bernecker, PhD, Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

The study was published online November 27 in JAMA Psychiatry.

Rigorously Tested Intervention

Data from the US Department of Defense (DoD) show that 325 active-duty US military members died by suicide in 2018 ― 40 more than in 2017.

In a recent study of 152 Army soldiers who had recently experienced a suicidal crisis, defined as a suicide attempt or suicidal thoughts, those who received brief CBT plus treatment as usual were significantly less likely to attempt suicide during the following 2 years than their peers who received treatment as usual.

Brief CBT is "one of the few interventions for service members with suicidal thoughts and behaviors that has been rigorously tested in a randomized controlled trial," Bernecker said.

"Because it appeared so promising, we thought it would be useful to take the next step of providing the DoD with information about cost-effectiveness," she added.

Using data from the study as well as epidemiologic datasets, the researchers created a decision analytic model that compared effects and costs of 12 individual brief CBT sessions plus treatment as usual vs only treatment as usual for soldiers who had recently experienced a suicidal crisis.

Treatment as usual could include a range of pharmacologic and psychological treatment options.

In the base-case analysis, compared with only treatment as usual, brief CBT would prevent roughly 23 to 25 more suicide attempts and 1 to 3 more suicide deaths per 100 patients treated.

Furthermore, a sensitivity analysis that assumed a range of treatment effects found that in most scenarios, brief CBT was cost-saving. Using the federal discount rate, the DoD would save between $15,000 and $16,630 per patient with brief CBT vs usual treatment.

In a worst-case scenario ― assuming the weakest plausible brief CBT effect sizes ― brief CBT cost an additional $1910 to $2250 per patient compared with usual treatment.

Brief CBT "is likely cost-saving relative to treatment as usual in addition to being more effective, and therefore represents an opportunity for the DoD to invest in human capital," the investigators conclude.

"If the DoD disseminates [brief] CBT for service members with recent suicidal crises, it will be critical to work with dissemination and implementation experts to ensure treatment fidelity through effective and efficient training," the authors note in their article. But even high training costs "may be outweighed by the cost savings in many scenarios, leaving brief CBT cost saving overall," they add.

The authors emphasize that the analysis only involved active-duty soldiers who had recently experienced suicidal crises. "There is no indication that brief CBT would be cost-effective for all service members reporting suicidal ideation," they point out.

Ongoing Problem

Reached for comment, retired military psychiatrist Elspeth Cameron Ritchie, MD, chief of psychiatry at Medstar Washington Hospital Center, Washington, DC, said, "Suicide in the military remains a problem, and any suicide is too many suicides."

Ritchie said that this is "an interesting and important study from a good group of researchers" and that the results show that "even in the most conservative analyses, brief CBT is cost-effective."

That finding is not surprising, said Ritchie, "even just thinking about the different aspects that are involved after a completed suicide, which people don't normally think about.

"One is that numerous investigations on many different levels are done after completed suicide, and that is very costly. Another is the death benefits that are paid out."

The study was supported in part by funding from the Military Suicide Research Consortium, an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs. Bernecker and Ritchie report no relevant financial relationships.

JAMA Psychiatry. Published online November 27, 2019. Abstract

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