incremental cost effectiveness of preventing depression in at risk adolescents dickerson

© 2011, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH

Incremental cost-effectiveness of preventing depression in at-risk adolescents

John Dickerson, MSMay 1, 201218th Annual HMO Research Network Conference, Seattle, WA


Frances L. Lynch, PhDJohn F. Dickerson, MS

Greg Clarke, PhDV Robin Weersing, PhDWilliam Beardslee, MD

Lynn DeBar, PhDTracey RG Gladstone, PhD

David Brent MDTami Mark, PhD

Giovanna Porta, MSJudy Garber, PhD


Acknowledgements

Boston Rachel Ammirati Jim Cooney Kate Ginnis Mary Kate Little Ellen Murachver Shula Ponet Phyllis Rothberg Carol Tee

Nashville Mary Jo Coiro Beth Donaghey Laurel Duncan Liz Ezell Jocelyn Carter Wendi Marien Rachel SwanMatt Morris Brandyn Street Sarah Frankel Katie Gallerani Christian Webb Mi Wu

Pittsburgh Yuan Brustoloni Satish Iyengar Brian McKain Nadine Melhem Deena Palenchar Tim Pitts Jennifer Spendley Ebony West Nathan Wigham Jamie Zelazny

Portland Kristina Booker Alison Firemark Bobbi Jo Yarborough Stephanie Hertert Sue Leung Tracy O’Connor Kevin Rogers Jane Wallace


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 - Revised 28.6 (8.0) 29.1 (8.5) .52

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)

Days of Antidepressant Medication

5.7 5.1

110.9 (78.7) 126.0 (86.5)

Days of Stimulant Medication3.1 1.9

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

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

ICER (95% CI)*

DFD QALY

Full Sample (n=316) 59 (11 -263)

35,434(6,350 – 157,594)

Conservative QALY weight [70%] NA 47,250(8,706 – 210,125)

Excluding cost outlier (n=315) 34 (2 – 125)

20,417(1,193 – 75,188)

Excluding patients with ANY inpatient utilization (n=308)

20(-1– 76)

12,267(-751 –45,581)

Outpatient costs only (n=316) 44(7 – 192)

26,618(4,063 – 115,461)

Parental depression** Dominated Dominated

No parental depression 14(-7 – 42)

8,683 (-4,157–25,156)


Figure 1. Cost-effectiveness Planes Base Case

Higher cost, worse outcome

Lower cost, worse outcome

Higher cost, better outcome

Lower cost, better outcome

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Incremental Change in CDRS-DFD1000 replications; adjusted for age, baseline costs, race, household income, and gender differences

CDRS-DFDs -- through month 8


Figure 2. Cost-effectiveness acceptability curve base case0

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Willingness to Pay

QALY (CDRS-DFD-based) at Month 8


Figure 3. Cost-effectiveness planes by subgroup





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Parental Depression at Baseline


Figure 4. Cost-effectiveness acceptability curves by subgroup0%

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Parental Depression at Baseline


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

Documents

health research

depression criteria

kaiser permanente center

greater risk of depression

years symptoms of depression

riskof depression episodes

health care systems

controlled research