Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON

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

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


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


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

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

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


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)


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

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


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


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)


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


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


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


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


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

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)


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).


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


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


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


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 $

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)


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


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)


Table 1 – Sample Description
CBP TAU p

Adolescents (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%) .78

CES-D (entry qualifying score) 18.5 (9.1) 18.8 (9.6) .83

Children’s Depression Rating Scale -
28.6 (8.0) 29.1 (8.5) .52
Revised

Household Income 81 (52.3%) 96 (63.6%) .045

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


Table 3. Service Use thru 9 months
% with any use Mean use (SD)
CBP TAU CBP TAU
Inpatient 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 5.1
Days of Antidepressant Medication 110.9 (78.7) 126.0 (86.5)
3.1 1.9
Days 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)

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 Costs
CBP Program Costs 277 (108)

Intervention Family costs 314 (200)

Total Intervention Costs 591 (286)

TOTAL COST 1,579 (4,073) 802 (2,126)

Table 5: Adjusted cost effectiveness ratios
ICER (95% CI)*
DFD QALY

Full 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 Dominated

No parental depression 14 8,683
(-7 – 42) (-4,157–25,156)

*. bias corrected; **. CBP never preferred for this group.

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

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

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

$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


Figure 4. Cost-effectiveness acceptability curves by subgroup

No Parental Depression at Baseline Parental Depression at Baseline
100%

100%
75%
75%

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

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


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


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


Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (15)

Similar to Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON

Similar to Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON (20)

More from HMO Research Network

More from HMO Research Network (20)

Incremental Cost Effectiveness of Preventing Depression in At Risk Adolescents DICKERSON