Language: Spanish
References: 43
Page: 301-308
PDF size: 126.91 Kb.
ABSTRACT
Introduction Depression is a public health problem that carries substantial costs for the individual and the society. In order to establish evidence-based priorities for resource allocation in mental health care, it is necessary to integrate the costs and effectiveness of interventions and specify the essential packages for their treatment.
The following are pioneering studies of cost-effectiveness for the treatment of depression: 1. compared psychopharmacology options (fluoxetine, imipramine and desipramine) to found no difference between drugs in terms of clinical efficacy, effect on quality of life and costs, and 2. evaluated cost-effectiveness of collaborative program of stepped care in primary care of persistent depression, to demonstrate a substantial increase in the effectiveness and additional moderate cost increase in comparison with usual treatment.
Recently, the World Health Organization convened the National Institute of Psychiatry Ramón de la Fuente, as a collaborating center, to participate in the «Selecting interventions that are cost-effective» labeled WHO-CHOICE (
CHOosing Interventions that are Cost-Effective).
This paper presents the findings of the evaluation of costeffectiveness of different clinical interventions for the treatment of depression in Mexico, considering its implementation in primary care services.
Method The cost-effectiveness unit of measure gathered by WHO (and used in this work) are the years of healthy life lost because of disease, named DALYs (Disability Adjusted Life Years).
DALYs result from the sum of years lost by premature mortality over the years that are lost through living in disability status. The advantages of using a measure of health at the population level as lost DALYs is that it allows comparing interventions for different diseases and addresses a relevant question from the avoidable burden health policy standpoint.
Interventions evaluated included: 1. tricyclic antidepressants, 2. new antidepressants (SSRIs), 3. brief psychotherapy, 4. trycliclic antidepressants + brief psychotherapy, 5. new antidepressants + brief psychotherapy, 6. tricyclic antidepressants + brief psychotherapy + proactive case management, and 7. new antidepressants + brief psychotherapy + proactive case management.
DALYs avoided as a result of each intervention or combination were calculated to determine its effectiveness. Both patients and program costs, a 3% discount by the process of converting future values to present ones, as well as an age adjustment giving less weight to year lived by the young were included. Finally, the cost of averted DALYs for each intervention was estimated to determine their cost effectiveness.
Results The combined strategies of proactive case management with psychotherapy plus antidepressants can be considered as the most effective one.
With the combination with tricyclic antidepressants, the number of DALYs averted was 207,171, and with SSRI of 217,568, corresponding to more than double of DALYs when tricyclic antidepressants are used alone and almost double when using only SSRIs.
The most expensive intervention was the combination of SSRIs with brief psychotherapy, with a total of $12,256 million pesos (972 million dollars), the least expensive treatment were tricyclic antidepressants, which involved $4,523 million pesos (359 million dollars).
Over 99% of the costs were from patient medications, and less than 1% from program and training costs. It is clear that the greatest cost is for added proactive case management.
The use of SSRI was the most cost-effective treatment (no combination) for the management of depression in Mexican primary care.
The most cost-effective combination was tryciclic antidepressants plus brief psychotherapy plus proactive case management.
Conclusions Although the are some studies on health economics in Mexico, most are directed to consider costs, and few ones have evaluated the costeffectiveness relationship of diagnostic and therapeutic interventions, lees son in the mental health field.
Antecedents of the present study in Mexico included a study that observed that psychiatric patients require more medical consultations, laboratory analysis, hospitalization days, surgeries and medication, in contrast with patients that never needed mental attention.
Nevertheless, investigations about cost-effectiveness relationship are rare. Just one study evaluates the costs of positive changes in psychopathology with antipsychotic medication for the treatment of schizophrenic patients. In this direction, the present work is the first effort to evaluate cost-effectiveness of different communitarian interventions to treat depression in Mexico.
According with our findings, also in México, the interventions available to treat depression in primary care level prevent a substantial number of DALYs: almost six times when SSRIs plus brief psychotherapy plus proactive case management are administered.
The specific effect of proactive case management is preventing relapses and increasing the time free of disease, which results in greater benefit to the patient, his family and the society. Thus, interventions are cost-effective despite the proactive case management significantly increases the cost of care to these patients.
In conclusion, the inclusion of psychosocial treatments is advantageous from a cost-effectiveness standpoint. Averted DALYs with these interventions are more «economic».
As observed in previous studies, a modest investment in improving depression produces greater gains in resource-limited environments. In Mexico, there is evidence that such interventions in primary care are effective when they are given by medical staff with a brief training, making them a promising tool for a cost-effective and evidence-based public policy.
REFERENCES
Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I et al. WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004;291:2581-2590.
Üstün TB, Ayuso-Mateos JL, Chatterji S, Mathers C et al. Global burden of depressive disorders in the year 2000. Br J Psychiatry 2004;184:386-392.
Lara MC, Medina-Mora ME, Borges G. Social cost of mental disorders: Disability and work days lost. Results from the Mexican survey of psychiatric epidemiology. Salud Mental 2007;30:4-11.
Medina-Mora ME, Borges G, Lara C, Benjet C et al. Prevalence, service use, and demographic correlates of 12-month DSM-IV psychiatric disorders in México: results from the Mexican National Comorbidity Survey. Psychol Med 2005;35:1–11.
Medina-Mora ME, Borges G, Lara MC, Benjet C et al. Prevalencia de trastornos mentales y uso de servicios: Resultados de la Encuesta Nacional de Epidemiología. Psiquiátrica en México. Salud Mental 2003;26:1-16.
Cipriani A, Malvini L, Furukawa TA, Barbui C. Relationship between quality of reports of antidepressant randomized controlled trials and treatment estimates: systematic review, meta-analysis, and meta-regression analysis. J Clin Psychopharmacol 2007;27:352-356.
Cuijpers P, Dekker J, Hollon SD, Andersson G. Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: a meta-analysis. J Clin Psychiatry 2009; 70:1219-1229.
Borges G, Wang PS, Medina-Mora ME. Lara C et al. Delay of first treatment of mental and substance use disorders in Mexico. Am J Public Health 2007;97:1638-1643.
Lloyd K, Jenkins R. The economics of depression in primary care. Department of Health Initiatives. Br J Psychiatry 1995;27:60-62.
Simon GE, Chisholm D, Treglia M, Bushnell D et al. Course of depression, health services costs, and work productivity in an international primary care study. Gen Hosp Psychiatry 2002;24:328-335.
Hu TW, He Y, Zhang M, Chen N. Economic costs of depression in China. Soc Psychiatry Psychiatr Epidemiol 2007;42:110-116.
Chisholm D. Dollars, DALYs and decisions: economic aspects of the mental health system. Geneva: World Health Organization; 2006.
Simon GE, VonKorff M, Heiligenstein JH, Revicki DA et al. Initial antidepressant choice in primary care. Effectiveness and cost of fluoxetine vs tricyclic antidepressants. JAMA 1996;275:1897-1902.
Simon GE, Katon WJ, VonKorff M, Unützer J et al. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. Am J Psychiatry 2001;158(10):1638-1644.
Araya R, Flynn T, Rojas G, Fritsch R et al. Cost-effectiveness of a primary care treatment program for depression in low-income women in Santiago, Chile. Am J Psychiatry 2006;163(8):1379-1387.
Stant AD, Ten Vergert EM, den Boer PC, Wiersma D. Cost-effectiveness of cognitive self-therapy in patients with depression and anxiety disorders. Acta Psychiatr Scand 2008;117:57-66.
De Graaf LE, Gerhards SA, Evers SM, Arntz A et al. Clinical and costeffectiveness of computerized cognitive behavioral therapy for depression in primary care: design of a randomized trial. BMC Public Health 2008;30:224-228.
Knapp M, Romeo R, Mogg A, Eranti S et al. Cost-effectiveness of transcranial magnetic stimulation vs. electroconvulsive therapy for severe depression: a multi-centre randomized controlled trial. J Affect Disord 2008;109:273-285.
Murray CJL, Lopez AD. The Global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press; 1996.
Chisholm D, Sanderson K, Ayuso-Mateos JL, Saxena S. Reducing the burden of depression: a population-level analysis of intervention costeffectiveness in 14 epidemiologically-defined sub-regions (WHOCHOICE). Br J Psychiatry 2004;184:393-403.
Katon W, Von Korff M, Lin E, Simon G et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 1999;56:1109-1115.
Solomon DA, Keller MB, Leon AC, Mueller TI et al. Recovery from depression: a 10-year prospective follow-up across multiple episodes. Arch Gen Psychiatry 1997;54:1001-1006.
Thase ME, Greenhouse JB, Frank E, Reynolds III CH et al. Treatment of major depression with psychotherapy or psychotherapy-pharmacotherapy combinations. Arch Gen Psychiatry 1997;54:1009-1015.
Malt UF, Robak OH, Madsbu HP, Bakke O et al. The Norwegian naturalistic treatment study of depression in primary practice (NORDEP) - I: randomised double blind study. BMJ 1999;318:1180-1184.
Chilvers C, Dewey M, Fielding K, Gretton V et al. Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms. BMJ 2001;322:1-5.
Araya R, Rojas G, Fritsch R, Gaete J et al. Treating depression in primary care in low-income women in Santiago,Chile: a randomised controlled trial. Lancet 2003;361:995-1000.
World Health Organization. The World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva: World Health Organization; 2001.
Callin AE. How much does an inadequate syphillis control program cost a country? Salud Publica Mex 1968;10:611-614.
Carlos F, Clark P, Maciel H, Tamayo JA. Direct costs of osteoporosis and hip fracture: an analysis for the Mexican Social Insurance Health Care System. Salud Publica Mex 2009;51:108-113.
Ruiz C, Ponce S. Socioeconomic profile and cost of treatment for patients with the acquired immunodeficiency syndrome treated at the Instituto Nacional de la Nutricion «Salvador Zubiran». Revista de Investigacion Clinica 1987;39 (Suppl):139-141.
Tellez J. Direct cost of partial epilepsy in Mexico. What is the next step? Arch Med Research 2006;37:808-809.
Reynales LM, Campuzano JC, Sesmaez S, Juarez SA et al. Costs of medical care for acute myocardial infarction attributable to tobacco consumption. Arch Med Research 2006;37(7):871-879.
Granados V, Velázquez R, Garduno J, Torres J et al. Resource utilization and costs of treating severe rotavirus diarrhea in young Mexican children from the health care provider perspective. Revista Investigación Clínica 2009;61:18-25.
García F, Del Angel G, Ramírez A, Malvaez M. Cost-effectiveness analysis of ceftriaxone and cefotaxime in the treatment of community-acquired pneumonia. Revista Investigación Clínica 2000;52:418-426.
García F, Nevarez A, Constantino P, Abud F et al. Cost-effectiveness of chronic hepatitis C treatment with thymosin alpha-1. Arch Med Research 20069;37:663-673.
Munoz M, Nevarez A, Garcia F, Mendieta S et al. Cost-effectiveness of the treatment of acute and chronic rhinosinusitis at the IMSS. Revista Investigacion Clinica 2007;59:197-205.
Martínez P, Medina-Mora ME, Campillo C. Evaluación del costo de utilización de los servicios en la práctica médica general. Salud Mental 1984;7:63-67.
Rascón R, Arredondo A, Tirado L, López M. Una aproximación al costo del tratamiento de las enfermedades mentales en México: depresión y esquizofrenia. Salud Mental 1988;21:43-47.
Parada I, Arredondo A, Arjonilla S. Costos de hospitalización por farmacodependencia para la población no asegurada en México. Salud Mental 2003;26:17-24.
De Gortari E, Castro E, Fernández J. Costs of operating psychiatric hospitals of the Ministry of Health in the Federal District. Salud Publica Mex 1993;35:563-568.
Palmer C, Brunner E, Ruiz-Flores L, Paez F et al. A cost-effectiveness clinical decision analysis model for treatment of Schizophrenia. Arch Med Research 2002;33:572-580.
López SR, Lara C, Kopelowicz A, Solano S et al. La Clave to increase psychosis literacy of Spanish-speaking community residents and family caregivers. J Consult Clin Psychol 2009;77:763-774.
Páez F, Robles R, Chávez J. Eficacia de una intervención psicológica impartida por un pasante de medicina para disminuir la sintomatología depresiva y ansiosa en mujeres rurales del estado de Jalisco. Trabajo de Investigación presentado en el Encuentro Nacional de Investigadores. Veracruz, México: Secretaría de Salud; 2002
Full text