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Incremental cost-effectiveness of           preventing depression in at-risk           adolescents                   John ...
Frances L. Lynch, PhD                                          John F. Dickerson, MS                                      ...
Acknowledgements     Boston                                           Pittsburgh               Rachel Ammirati         ...
Adolescent Depression  Point prevalence rates of 3-8%  Average age of first onset = 15 years  Lifetime prevalence rate ...
Consequences of Adolescent Depression     – Short Term      Difficulties in relationships      Impaired school and work ...
Consequences of Adolescent Depression     – Long Term       Poor functional outcomes in adulthood       Reduced quality ...
Risk Factors for Depression      Parental Depression             Increases risk of youth depression by 40%      Sub-syn...
Parental Depression   Strongest risk factor for depression in youth   4X greater risk of depression in children of depre...
Treatment of Adolescent Depression      Evidence for pharmacotherapy and psychotherapy       (interpersonal psychotherapy...
Prevention and Mental Health           Clinical resources focused on current crises           Researchers and clinicians...
Studies evaluating prevention interventions       Multiple RCT have demonstrated that it is possible        to prevent de...
Prevention of Depression (POD) Study      Specific Aims  To test the efficacy of a cognitive-behavioral (CB)   program fo...
Inclusion Criteria  At least one biological parent had a current and/or   past depressive episode  Adolescents (13-17 ye...
Exclusion Criteria     Neither parent nor the teen could be bipolar or      schizophrenic     Teens could not           ...
Study Design              RCT              4 sites (Nashville, TN; Boston, MA;               Pittsburgh PA; Portland OR)...
POD Prevention Program     •     Cognitive therapy approach     •     Groups ranged in size from 3 to 10     •     Mixed g...
Methods                 Participants assessed at baseline, 3, and 9                  months blind to intervention status ...
Clinical Outcome Measures      Schedule for Affective Disorders and       Schizophrenia for School- Age Children       (K...
Clinical Effects for the CEA                  Depression Free Days (DFD)                  Quality-adjusted Life Years (Q...
Cost Data         Comprehensive costs of interventions, usual          care across service sectors, parent time costs    ...
Types of Cost Included            • Interventions                  – CBP                  – Including training and supervi...
Valuation of resources              Study financial records             • Estimated cost of Usual Care services          ...
Statistical Analyses      Analyses were intention-to-treat basis      Hypotheses tests from based on group variable in O...
Analyses                  Main                         All randomized youth                  Sensitivity               ...
Missing Data      Complete clinical outcome and health services data on 87%       of participants      Multiple imputati...
Table 1 – Sample Description                                       CBP                TAU             pAdolescents (N=316)...
Incremental Differences in Clinical     Outcomes at 9 months              CBP group had:                     13 more DFD...
Table 3. Service Use thru 9 months                                         % with any use              Mean use (SD)      ...
Table 4. Cost (2009 USD) thru 9 months                            CBP     TAU        CBP           TAU Non-Protocol Costs%...
Table 5: Adjusted cost effectiveness ratios                                                                            ICE...
Figure 1. Cost-effectiveness Planes Base Case                                                                     CDRS-DFD...
Figure 2. Cost-effectiveness acceptability curve base case                                                                ...
Figure 3. Cost-effectiveness planes by subgroup                                                 No Parental Depression at ...
Figure 4.       Cost-effectiveness acceptability curves by subgroup                                                       ...
Preliminary Conclusions        CBP increased DFD and QALYs        CBP significantly more expensive        CBP is very l...
Limitations              Did not include productivity costs for youth                     Adult literature suggests prod...
Future Directions      Replication over longer period of time             Clinical outcomes and costs may change over ti...
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Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON

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Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON

  1. 1. Incremental cost-effectiveness of preventing depression in at-risk adolescents John Dickerson, MS May 1, 2012 18th Annual HMO Research Network Conference, Seattle, WA© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  2. 2. Frances L. Lynch, PhD John F. Dickerson, MS Greg Clarke, PhD V Robin Weersing, PhD William Beardslee, MD Lynn DeBar, PhD Tracey RG Gladstone, PhD David Brent MD Tami Mark, PhD Giovanna Porta, MS Judy Garber, PhD© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  3. 3. Acknowledgements Boston Pittsburgh  Rachel Ammirati  Yuan Brustoloni Satish Iyengar  Jim Cooney  Brian McKain Nadine Melhem  Kate Ginnis  Deena Palenchar Tim Pitts  Mary Kate Little  Jennifer Spendley Ebony West  Ellen Murachver  Nathan Wigham Jamie Zelazny  Shula Ponet  Phyllis Rothberg  Carol Tee Portland Nashville   Kristina Booker Alison Firemark  Mary Jo Coiro Beth Donaghey  Bobbi Jo Yarborough  Laurel Duncan Liz Ezell  Stephanie Hertert  Jocelyn Carter Wendi Marien  Sue Leung  Rachel Swan Matt Morris  Tracy O’Connor  Brandyn Street Sarah Frankel  Kevin Rogers  Katie Gallerani Christian Webb  Jane Wallace  Mi Wu© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  4. 4. Adolescent Depression  Point prevalence rates of 3-8%  Average age of first onset = 15 years  Lifetime prevalence rate of depression by end of adolescence = 25%  Relapse rate of 40% within 2 years; 75% within 5 years  Symptoms of depression in adolescence are associated with risk for full-blown disorder  Most cases of recurrent adult depression have initial onsets during adolescence© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  5. 5. Consequences of Adolescent Depression – Short Term  Difficulties in relationships  Impaired school and work performance  Increased risk for teen pregnancy  Increased risk for substance abuse  Reduced quality of life  Higher rates of suicide attempts  Higher health care costs  Greater use of school and other social services© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  6. 6. Consequences of Adolescent Depression – Long Term  Poor functional outcomes in adulthood  Reduced quality of life  Higher rates of suicide attempts  More psychiatric and medical hospitalizations  Lower educational attainment  More time out of work© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  7. 7. Risk Factors for Depression  Parental Depression  Increases risk of youth depression by 40%  Sub-syndromal Depression symptoms  Symptoms but not meeting diagnostic criteria  Increases risk of youth depression by 30%  Previous Episodes of Depression (Weisz et al. 2006; Birmaher & Brent 2007; TADS Team 2004; NICE 2008)© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  8. 8. Parental Depression  Strongest risk factor for depression in youth  4X greater risk of depression in children of depressed parents  Amongst adolescents seeking services for depression most have parents with current mood disorders  More internalizing and externalizing disorders, cognitive delays, academic and social difficulties© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  9. 9. Treatment of Adolescent Depression  Evidence for pharmacotherapy and psychotherapy (interpersonal psychotherapy, cognitive-behavioral psychotherapy)  Only 25% of youth who meet depression criteria receive any type of treatment  50-60% of those treated in controlled research studies show improvement  Current clinical practice fails to alleviate the majority of the disease burden associated with depression© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  10. 10. Prevention and Mental Health  Clinical resources focused on current crises  Researchers and clinicians trained in pathology- based models  Insurance and health care systems designed to provide treatment of disease, prevention is typically less well funded  Most insurance does not currently cover prevention services for mental health© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  11. 11. Studies evaluating prevention interventions  Multiple RCT have demonstrated that it is possible to prevent depression episodes using psychotherapeutic interventions including CB approaches  In particular, two studies have demonstrated that a CB Prevention intervention can reduce the risk of depression episodes in youth of depressed parents (Clarke et al. 2001; Lynch et al. 2005; Garber et al. 2010)© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  12. 12. Prevention of Depression (POD) Study Specific Aims  To test the efficacy of a cognitive-behavioral (CB) program for preventing depression in at-risk adolescents, across 4 sites  To explore possible moderators  To examine cost-effectiveness of program compared to TAU© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  13. 13. Inclusion Criteria  At least one biological parent had a current and/or past depressive episode  Adolescents (13-17 years old) had  Current subsyndromal symptoms of depression [CES-D > 20]  A history of a diagnosed depressive disorder  Or both  Both a selective and indicated sample© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  14. 14. Exclusion Criteria  Neither parent nor the teen could be bipolar or schizophrenic  Teens could not  currently meet criteria for MDD or dysthymia  currently be taking any anti-depressant medication  have received cognitive-behavioral therapy© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  15. 15. Study Design  RCT  4 sites (Nashville, TN; Boston, MA; Pittsburgh PA; Portland OR)  Adolescents aged 13-17 years  At-risk for depression  316 youth participated in study© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  16. 16. POD Prevention Program • Cognitive therapy approach • Groups ranged in size from 3 to 10 • Mixed gender, expected 60-80% female • 8 weekly Acute sessions, 90 minute per session • 6 monthly Continuation sessions, also 90 min’s • Parent group: weeks 1 and 8 (variable attendance) • Led by Master’s level therapists© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  17. 17. Methods  Participants assessed at baseline, 3, and 9 months blind to intervention status  Randomized to either CBP or UC  All participants could initiate or continue any health care services, non-health services (e.g., school, social services)© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  18. 18. Clinical Outcome Measures  Schedule for Affective Disorders and Schizophrenia for School- Age Children (KSADS) Present and Lifetime Version (Kaufman et al. 1997)  Clinical Global Impression Scale (CGI) - Improvement (Guy 1976)  Child Depression Rating Scale (CDRS) –Revised (Poznanski et al. 1994; Brent et al. 2008).© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  19. 19. Clinical Effects for the CEA  Depression Free Days (DFD)  Quality-adjusted Life Years (QALY)  Used clinical data at each assessment  Use linear interpolation between clinical time points  Summed over 9 months© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  20. 20. Cost Data  Comprehensive costs of interventions, usual care across service sectors, parent time costs  Collected concurrent with trial  Sources of data  Interviews with study personnel  Study activity and financial records  Child and Adolescent Services Assessment (CASA)  Parent and youth report© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  21. 21. Types of Cost Included • Interventions – CBP – Including training and supervision • Usual Care health care  General medical and mental health specialty • Comprehensive services outside Health  Including school, social services, juvenile justice • Family costs  Time, travel© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  22. 22. Valuation of resources  Study financial records • Estimated cost of Usual Care services • Unit costs from large databases including MEPS, Marketscan Claims Databases, Previous Studies (Lynch et al. 2005; Lynch et al. 2011; Domino et al. 2008) • Parent and participant reported costs for outside health and other costs • Estimated parent time costs using human capital approach • All resources in 2009 $© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  23. 23. Statistical Analyses  Analyses were intention-to-treat basis  Hypotheses tests from based on group variable in OLS regression models  Bootstrapping with a single model with 1000 replications  (BCa; Thompson et al. 2000; O’Brien & Briggs 2002; O’Brien et al. 1994).  Net benefit regression framework to estimate  Cost Effectiveness Acceptability Curve (CEAC)  Examine differential CE for subgroups indicated by primary clinical analyses (Hoch et al. 2005)© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  24. 24. Analyses  Main  All randomized youth  Sensitivity  Alternative QALY weights  Removal of outliers  Sub-group analyses  Based on clinical moderation analyses  Youth whose parents were actively depressed at baseline© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  25. 25. Missing Data  Complete clinical outcome and health services data on 87% of participants  Multiple imputation with chained equations (Royston 2004; Royston 2005) using STATA  Assumed missing at random  Included all non-missing values at all time points and baseline demographics in the models  Created five imputation datasets (Little & Rubin 2002)© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  26. 26. Table 1 – Sample Description CBP TAU pAdolescents (N=316) n=159 n=157 Age 14.8 (1.5) 14.8 (1.3) .66 Female 93 (58.5%) 92 (58.6%) .98 Caucasian 129 (82.7%) 125 (80.6%) .64 Latino/Hispanic 10 (6.3%) 11 (7.1%) .78CES-D (entry qualifying score) 18.5 (9.1) 18.8 (9.6) .83Children’s Depression Rating Scale - 28.6 (8.0) 29.1 (8.5) .52RevisedHousehold Income 81 (52.3%) 96 (63.6%) .045
  27. 27. Incremental Differences in Clinical Outcomes at 9 months  CBP group had:  13 more DFDs (p=.008)  0.022 more QALYs (p=.008)  DFD increased over time for both groups© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  28. 28. Table 3. Service Use thru 9 months % with any use Mean use (SD) CBP TAU CBP TAUInpatient Mental Health Days 1.9 1.3 33.3 (46.5) 11.0 (9.9)Inpatient Alcohol or Drug Days 1.3 0 24.0 (28.3)Counseling or Medication Visits 29.6 27.4 11.3 (17.3) 9.1 (14.3)Day Hospital Days 0.6 0 106 (--)Alcohol or Drug Treatment Visits 1.3 0.6 8.5 (6.4) 33.0 (--)Crisis Services 2.5 0.6 24.0 (34.5) 2.0 (--)Medical doctor visits 6.3 11.5 2.1 (1.5) 1.8 (1.1)Emergency Room Visits 1.9 1.3 1 (--) 2.5 (2.1) 5.7 5.1Days of Antidepressant Medication 110.9 (78.7) 126.0 (86.5) 3.1 1.9Days of Stimulant Medication 105.6 (74.2) 61.0 (30.0)Days of Other Psych Medication 0.0 1.3 73.0 (70.4) 153.0 (--)ANY School Services 20.1 22.9 29.1 (61.1) 44.9 (105.2)Juvenile correction contact 1.3 3.2 10.0 (2.8) 5.2 (7.3)
  29. 29. Table 4. Cost (2009 USD) thru 9 months CBP TAU CBP TAU Non-Protocol Costs% with Any Cost/Mean Cost (SD) 52.1 50.3 882 (3,285) 740 (2,021)Family Costs 38.2 36.9 55 (170) 109 (470) Intervention CostsCBP Program Costs 277 (108)Intervention Family costs 314 (200)Total Intervention Costs 591 (286)TOTAL COST 1,579 (4,073) 802 (2,126)
  30. 30. Table 5: Adjusted cost effectiveness ratios ICER (95% CI)* DFD QALYFull Sample (n=316) 59 35,434 (11 -263) (6,350 – 157,594)Conservative QALY weight [70%] NA 47,250 (8,706 – 210,125)Excluding cost outlier (n=315) 34 20,417 (2 – 125) (1,193 – 75,188)Excluding patients with ANY 20 12,267 (-1– 76) (-751 –45,581)inpatient utilization (n=308)Outpatient costs only (n=316) 44 26,618 (7 – 192) (4,063 – 115,461)Parental depression** Dominated DominatedNo parental depression 14 8,683 (-7 – 42) (-4,157–25,156) *. bias corrected; **. CBP never preferred for this group.
  31. 31. Figure 1. Cost-effectiveness Planes Base Case CDRS-DFDs -- through month 8 $2,000 Higher cost, better outcome Higher cost, worse outcome Incremental Total Cost $1,000 $0 -$1,000 -$2,000 Lower cost, worse outcome Lower cost, better outcome -40 -30 -20 -10 0 10 20 30 40 Incremental Change in CDRS-DFD 1000 replications; adjusted for age, baseline costs, race, household income, and gender differences© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  32. 32. Figure 2. Cost-effectiveness acceptability curve base case QALY (CDRS-DFD-based) at Month 8 100% Probability Treatment is Cost-Effective 75% 50% 25% 0% $0 $50,000 $100,000 $150,000 $200,000 $300,000 $400,000 $500,000 Willingness to Pay© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  33. 33. Figure 3. Cost-effectiveness planes by subgroup No Parental Depression at Baseline Parental Depression at Baseline $4,000 $4,000 Higher cost, worse outcome Higher cost, worse outcome Higher cost, better outcome Higher cost, better outcome $2,000 $2,000 Incremental Total Cost Incremental Total Cost $1,000 $1,000 $0 $0 -$1,000 -$1,000 -$2,000 -$2,000 Lower cost, better outcome Lower cost, better outcome Lower cost, worse outcome =$4,000 =$4,000 Lower cost, worse outcome -40 -30 -20 -10 0 10 20 30 40 -40 -30 -20 -10 0 10 20 30 40 Incremental Change in CDRS-DFD Incremental Change in CDRS-DFD 1000 replications; adjusted for age, baseline costs, race, household income, and gender differences 1000 replications; adjusted for age, baseline costs, race, household income, and gender differences© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  34. 34. Figure 4. Cost-effectiveness acceptability curves by subgroup No Parental Depression at Baseline Parental Depression at Baseline 100% 100% 75% 75%Probability Treatment is Cost-Effective Probability Treatment is Cost-Effective 50% 50% 25% 25% 0% 0% $0 $50,000 $100,000 $150,000 $200,000 $300,000 $400,000 $500,000 $0 $50,000 $100,000 $150,000 $200,000 $300,000 $400,000 $500,000 Willingness to Pay Willingness to Pay© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  35. 35. Preliminary Conclusions  CBP increased DFD and QALYs  CBP significantly more expensive  CBP is very likely to be cost-effective compared to many medical services currently covered by most insurance programs  CBP highly cost-effective for youth whose parent’s depression was in REMISSION at baseline© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  36. 36. Limitations  Did not include productivity costs for youth  Adult literature suggests productivity is the largest cost of depression  Suggests substantial lost time from school  Did not include all family costs  Included typical parent time costs  Did NOT include caregiving time, coordination, other  Methods for calculating QALYs  Followed standard methods, but did not directly measure utility weights  No utility weights in youth available – used adult weights  Weights do not account for comorbidity© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH
  37. 37. Future Directions  Replication over longer period of time  Clinical outcomes and costs may change over time  Data are collected through 32 months  Need better information on sub-groups  Larger sample could help to understand moderation of clinical and cost outcomes  May need to adapt interventions for some risk groups  Co-treatment of parent and youth, sequential treatment of parent and youth  Need for Preference Based HRQL in youth  Evidence that depression negatively affects HRQL in youth  No preference based QALY weights for youth© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

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