Publications by authors named "Joran Lokkerbol"

31 Publications

Patients' and Psychologists' Preferences for Feedback Reports on Expected Mental Health Treatment Outcomes: A Discrete-Choice Experiment.

Adm Policy Ment Health 2022 Apr 15. Epub 2022 Apr 15.

Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands.

In recent years, there has been an increasing focus on routine outcome monitoring (ROM) to provide feedback on patient progress during mental health treatment, with some systems also predicting the expected treatment outcome. The aim of this study was to elicit patients' and psychologists' preferences regarding how ROM system-generated feedback reports should display predicted treatment outcomes. In a discrete-choice experiment, participants were asked 12-13 times to choose between two ways of displaying an expected treatment outcome. The choices varied in four different attributes: representation, outcome, predictors, and advice. A conditional logistic regression was used to estimate participants' preferences. A total of 104 participants (68 patients and 36 psychologists) completed the questionnaire. Participants preferred feedback reports on expected treatment outcome that included: (a) both text and images, (b) a continuous outcome or an outcome that is expressed in terms of a probability, (c) specific predictors, and (d) specific advice. For both patients and psychologists, specific predictors appeared to be most important, specific advice was second most important, a continuous outcome or a probability was third most important, and feedback that includes both text and images was fourth in importance. The ranking in importance of both the attributes and the attribute levels was identical for patients and psychologists. This suggests that, as long as the report is understandable to the patient, psychologists and patients can use the same ROM feedback report, eliminating the need for ROM administrators to develop different versions.
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http://dx.doi.org/10.1007/s10488-022-01194-2DOI Listing
April 2022

Longitudinal clinical and functional outcome in distinct cognitive subgroups of first-episode psychosis: a cluster analysis.

Psychol Med 2021 Oct 19:1-11. Epub 2021 Oct 19.

Early Intervention Team, GGZ Centraal, Amersfoort, The Netherlands.

Background: Cognitive deficits may be characteristic for only a subgroup of first-episode psychosis (FEP) and the link with clinical and functional outcomes is less profound than previously thought. This study aimed to identify cognitive subgroups in a large sample of FEP using a clustering approach with healthy controls as a reference group, subsequently linking cognitive subgroups to clinical and functional outcomes.

Methods: 204 FEP patients were included. Hierarchical cluster analysis was performed using baseline brief assessment of cognition in schizophrenia (BACS). Cognitive subgroups were compared to 40 controls and linked to longitudinal clinical and functional outcomes (PANSS, GAF, self-reported WHODAS 2.0) up to 12-month follow-up.

Results: Three distinct cognitive clusters emerged: relative to controls, we found one cluster with preserved cognition (n = 76), one moderately impaired cluster (n = 74) and one severely impaired cluster (n = 54). Patients with severely impaired cognition had more severe clinical symptoms at baseline, 6- and 12-month follow-up as compared to patients with preserved cognition. General functioning (GAF) in the severely impaired cluster was significantly lower than in those with preserved cognition at baseline and showed trend-level effects at 6- and 12-month follow-up. No significant differences in self-reported functional outcome (WHODAS 2.0) were present.

Conclusions: Current results demonstrate the existence of three distinct cognitive subgroups, corresponding with clinical outcome at baseline, 6- and 12-month follow-up. Importantly, the cognitively preserved subgroup was larger than the severely impaired group. Early identification of discrete cognitive profiles can offer valuable information about the clinical outcome but may not be relevant in predicting self-reported functional outcomes.
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http://dx.doi.org/10.1017/S0033291721004153DOI Listing
October 2021

Predicting Future Service Use in Dutch Mental Healthcare: A Machine Learning Approach.

Adm Policy Ment Health 2022 01 31;49(1):116-124. Epub 2021 Aug 31.

Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands.

A mental healthcare system in which the scarce resources are equitably and efficiently allocated, benefits from a predictive model about expected service use. The skewness in service use is a challenge for such models. In this study, we applied a machine learning approach to forecast expected service use, as a starting point for agreements between financiers and suppliers of mental healthcare. This study used administrative data from a large mental healthcare organization in the Netherlands. A training set was selected using records from 2017 (N = 10,911), and a test set was selected using records from 2018 (N = 10,201). A baseline model and three random forest models were created from different types of input data to predict (the remainder of) numeric individual treatment hours. A visual analysis was performed on the individual predictions. Patients consumed 62 h of mental healthcare on average in 2018. The model that best predicted service use had a mean error of 21 min at the insurance group level and an average absolute error of 28 h at the patient level. There was a systematic under prediction of service use for high service use patients. The application of machine learning techniques on mental healthcare data is useful for predicting expected service on group level. The results indicate that these models could support financiers and suppliers of healthcare in the planning and allocation of resources. Nevertheless, uncertainty in the prediction of high-cost patients remains a challenge.
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http://dx.doi.org/10.1007/s10488-021-01150-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8732820PMC
January 2022

Health-economic evaluation of psychological interventions for depression prevention: Systematic review.

Clin Psychol Rev 2021 08 10;88:102064. Epub 2021 Jul 10.

Biomedical Research Institute of Malaga (IBIMA), C/ Sevilla 23, 29009 Málaga, Spain; Prevention and Health Promotion Research Network (redIAPP), ISCIII, Gran Via de les Corts Catalanes, 587, 08007 Barcelona, Spain; El Palo' Health Centre, Health District of Primary Care Málaga-Guadalhorce, SAS, Av. Salvador Allende, 159, 29018 Málaga, Spain; Department of Public Health and Psychiatry, University of Málaga, Bulevar Louis Pasteur, 32, 29010 Málaga, Spain.

Psychological interventions have been proven to be effective to prevent depression, however, little is known on the cost-effectiveness of psychological interventions for the prevention of depression in various populations. A systematic review was conducted using PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Econlit, NHS Economic Evaluations Database, NHS Health Technology Assessment and OpenGrey up to January 2021. Only health-economic evaluations based on randomized controlled trials of psychological interventions to prevent depression were included. Independent evaluators selected studies, extracted data and assessed the quality using the Consensus on Health Economic Criteria and the Cochrane Risk of Bias Tool. Twelve trial-based economic evaluations including 5929 participants from six different countries met the inclusion criteria. Overall, the quality of most economic evaluations was considered good, but some studies have some risk of bias. Setting the willingness-to-pay upper limit to US$40,000 (2018 prices) for gaining one quality adjusted life year (QALY), eight psychological preventive interventions were likely to be cost-effective compared to care as usual. The likelihood of preventive psychological interventions being more cost-effective than care as usual looks promising, but more economic evaluations are needed to bridge the many gaps that remain in the evidence-base. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.
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http://dx.doi.org/10.1016/j.cpr.2021.102064DOI Listing
August 2021

Mapping of the World Health Organization's Disability Assessment Schedule 2.0 to disability weights using the Multi-Country Survey Study on Health and Responsiveness.

Int J Methods Psychiatr Res 2021 09 10;30(3):e1886. Epub 2021 Jul 10.

Division of Country Health Policies and Systems, Regional Office for Europe, World Health Organization, Copenhagen, Denmark.

Objectives: To develop and test an internationally applicable mapping function for converting WHODAS-2.0 scores to disability weights, thereby enabling WHODAS-2.0 to be used in cost-utility analyses and sectoral decision-making.

Methods: Data from 14 countries were used from the WHO Multi-Country Survey Study on Health and Responsiveness, administered among nationally representative samples of respondents aged 18+ years who were non-institutionalized and living in private households. For the combined total of 92,006 respondents, available WHODAS-2.0 items (for both 36-item and 12-item versions) were mapped onto disability weight estimates using a machine learning approach, whereby data were split into separate training and test sets; cross-validation was used to compare the performance of different regression and penalized regression models. Sensitivity analyses considered different imputation strategies and compared overall model performance with that of country-specific models.

Results: Mapping functions converted WHODAS-2.0 scores into disability weights; R-squared values of 0.700-0.754 were obtained for the test data set. Penalized regression models reached comparable performance to standard regression models but with fewer predictors. Imputation had little impact on model performance. Model performance of the generic model on country-specific test sets was comparable to model performance of country-specific models.

Conclusions: Disability weights can be generated with good accuracy using WHODAS 2.0 scores, including in national settings where health state valuations are not directly available, which signifies the utility of WHODAS as an outcome measure in evaluative studies that express intervention benefits in terms of QALYs gained.
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http://dx.doi.org/10.1002/mpr.1886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8412228PMC
September 2021

More than cost-effectiveness? Applying a second-stage filter to improve policy decision making.

Health Expect 2021 08 1;24(4):1413-1423. Epub 2021 Jun 1.

Department of Science and Engineering, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands.

Background: Apart from cost-effectiveness, considerations like equity and acceptability may affect health-care priority setting. Preferably, priority setting combines evidence evaluation with an appraisal procedure, to elicit and weigh these considerations.

Objective: To demonstrate a structured approach for eliciting and evaluating a broad range of assessment criteria, including key stakeholders' values, aiming to support decision makers in priority setting.

Methods: For a set of cost-effective substitute interventions for depression care, the appraisal criteria were adopted from the Australian Assessing Cost-Effectiveness initiative. All substitute interventions were assessed in an appraisal, using focus group discussions and semi-structured interviews conducted among key stakeholders.

Results: Appraisal of the substitute cost-effective interventions yielded an overview of considerations and an overall recommendation for decision makers. Two out of the thirteen pairs were deemed acceptable and realistic, that is investment in therapist-guided and Internet-based cognitive behavioural therapy instead of cognitive behavioural therapy in mild depression, and investment in combination therapy rather than individual psychotherapy in severe depression. In the remaining substitution pairs, substantive issues affected acceptability. The key issues identified were as follows: workforce capacity, lack of stakeholder support and the need for change in clinicians' attitude.

Conclusions: Systematic identification of stakeholders' considerations allows decision makers to prioritize among cost-effective policy options. Moreover, this approach entails an explicit and transparent priority-setting procedure and provides insights into the intended and unintended consequences of using a certain health technology.

Patient Contribution: Patients were involved in the conduct of the study for instance, by sharing their values regarding considerations relevant for priority setting.
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http://dx.doi.org/10.1111/hex.13277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369110PMC
August 2021

Real-World Treatment Costs and Care Utilization in Patients with Major Depressive Disorder With and Without Psychiatric Comorbidities in Specialist Mental Healthcare.

Pharmacoeconomics 2021 06 16;39(6):721-730. Epub 2021 Mar 16.

University of Groningen, Department of Science and Engineering, Groningen Research Institute of Pharmacy, Groningen, The Netherlands.

Background: The majority of patients with major depressive disorder (MDD) have comorbid mental conditions.

Objectives: Since most cost-of-illness studies correct for comorbidity, this study focuses on mental healthcare utilization and treatment costs in patients with MDD including psychiatric comorbidities in specialist mental healthcare, particularly patients with a comorbid personality disorder (PD).

Methods: The Psychiatric Case Register North Netherlands contains administrative data of specialist mental healthcare providers. Treatment episodes were identified from uninterrupted healthcare use. Costs were calculated by multiplying care utilization with unit prices (price level year: 2018). Using generalized linear models, cost drivers were investigated for the entire cohort.

Results: A total of 34,713 patients had MDD as a primary diagnosis over the period 2000-2012. The number of patients with psychiatric comorbidities was 24,888 (71.7%), including 13,798 with PD. Costs were highly skewed, with an average ± standard deviation cost per treatment episode of €21,186 ± 74,192 (median €2320). Major cost drivers were inpatient days and daycare days (50 and 28% of total costs), occurring in 12.7 and 12.5% of episodes, respectively. Compared with patients with MDD only (€11,612), costs of patients with additional PD and with or without other comorbidities were, respectively, 2.71 (p < .001) and 2.06 (p < .001) times higher and were 1.36 (p < .001) times higher in patients with MDD and comorbidities other than PD. Other cost drivers were age, calendar year, and first episodes.

Conclusions: Psychiatric comorbidities (especially PD) in addition to age and first episodes drive costs in patients with MDD. Knowledge of cost drivers may help in the development of future stratified disease management programs.
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http://dx.doi.org/10.1007/s40273-021-01012-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166711PMC
June 2021

Design of a health-economic Markov model to assess cost-effectiveness and budget impact of the prevention and treatment of depressive disorder.

Expert Rev Pharmacoecon Outcomes Res 2021 Oct 23;21(5):1031-1042. Epub 2020 Nov 23.

Centre for Economic Evaluation and Machine Learning, Department of Public Mental Health, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands.

: To describe the design of 'DepMod,' a health-economic Markov model for assessing cost-effectiveness and budget impact of user-defined preventive interventions and treatments in depressive disorders.: DepMod has an epidemiological layer describing how a cohort of people can transition between health states (sub-threshold depression, first episode of mild, moderate or severe depression (partial) remission, recurrence, death). Superimposed on the epidemiological layer, DepMod has an intervention layer consisting of a reference scenario and alternative scenario comparing the effectiveness and cost-effectiveness of a user-defined package of preventive interventions and psychological and pharmacological treatments of depression. Results are presented in terms of quality-adjusted life years (QALYs) gained and healthcare expenditure. Costs and effects can be modeled over 5 years and are subjected to probabilistic sensitivity analysis.: DepMod was used to assess the cost-effectiveness of scaling up preventive interventions for treating people with subclinical depression, which showed that there is an 82% probability that scaling up prevention is cost-effective given a willingness-to-pay threshold of €20,000 per QALY.: DepMod is a Markov model that assesses the cost-utility and budget impact of different healthcare packages aimed at preventing and treating depression and is freely available for academic purposes upon request at the authors.
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http://dx.doi.org/10.1080/14737167.2021.1844566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475718PMC
October 2021

Design of a health-economic Markov model to assess cost-effectiveness and budget impact of the prevention and treatment of depressive disorder.

Expert Rev Pharmacoecon Outcomes Res 2021 Oct 23;21(5):1031-1042. Epub 2020 Nov 23.

Centre for Economic Evaluation and Machine Learning, Department of Public Mental Health, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands.

: To describe the design of 'DepMod,' a health-economic Markov model for assessing cost-effectiveness and budget impact of user-defined preventive interventions and treatments in depressive disorders.: DepMod has an epidemiological layer describing how a cohort of people can transition between health states (sub-threshold depression, first episode of mild, moderate or severe depression (partial) remission, recurrence, death). Superimposed on the epidemiological layer, DepMod has an intervention layer consisting of a reference scenario and alternative scenario comparing the effectiveness and cost-effectiveness of a user-defined package of preventive interventions and psychological and pharmacological treatments of depression. Results are presented in terms of quality-adjusted life years (QALYs) gained and healthcare expenditure. Costs and effects can be modeled over 5 years and are subjected to probabilistic sensitivity analysis.: DepMod was used to assess the cost-effectiveness of scaling up preventive interventions for treating people with subclinical depression, which showed that there is an 82% probability that scaling up prevention is cost-effective given a willingness-to-pay threshold of €20,000 per QALY.: DepMod is a Markov model that assesses the cost-utility and budget impact of different healthcare packages aimed at preventing and treating depression and is freely available for academic purposes upon request at the authors.
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http://dx.doi.org/10.1080/14737167.2021.1844566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475718PMC
October 2021

Economic evaluations of non-pharmacological interventions and cost-of-illness studies in bipolar disorder: A systematic review.

J Affect Disord 2020 11 15;276:388-401. Epub 2020 Jul 15.

Center for Economic Evaluation and Machine Learning, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, Netherlands. Electronic address:

Background Bipolar disorder (BD) is associated with substantial societal burden. Therefore, economic studies in BD are becoming increasingly important. The goal of the current study is three-fold: (1) summarize the evidence regarding economic evaluations (EEs) of non-pharmacological interventions for BD, (2) summarize cost-of-illness studies (COIs) for BD published 2012 or later and (3) assess the quality of the identified studies. Methods A systematic search was conducted in MedLine, EMBASE and PsycINFO. For both EEs and COIs, quality assessments were conducted and general and methodological characteristics of the studies were extracted. Outcomes included incremental-cost-effectiveness ratios for EEs and direct and indirect costs for COIs. Results Eight EEs and ten COIs were identified. The included studies revealed high heterogeneity in general and methodological characteristics and study quality. All interventions resulted in improved clinical outcomes. Five studies additionally concluded decreased total costs. For COIs, we found a wide range of direct ($881-$27,617) and indirect cost estimates per capita per year ($1,568-$116,062). Limitations High heterogeneity in terms of interventions, study design and outcomes made it difficult to compare results across studies. Conclusions Interventions improved clinical outcomes in all studies and led to cost-savings in five studies. Findings suggest that non-pharmacological intervention for BD might be cost-effective. Studies on the costs of BD revealed that BD has a substantial economic burden. However, we also found that the number of EEs was relatively low and methodology was heterogenous and therefore encourage future research to widen the body of knowledge in this research field and use standardized methodology.
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http://dx.doi.org/10.1016/j.jad.2020.06.064DOI Listing
November 2020

Economic evaluations of non-pharmacological interventions and cost-of-illness studies in bipolar disorder: A systematic review.

J Affect Disord 2020 11 15;276:388-401. Epub 2020 Jul 15.

Center for Economic Evaluation and Machine Learning, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, Netherlands. Electronic address:

Background Bipolar disorder (BD) is associated with substantial societal burden. Therefore, economic studies in BD are becoming increasingly important. The goal of the current study is three-fold: (1) summarize the evidence regarding economic evaluations (EEs) of non-pharmacological interventions for BD, (2) summarize cost-of-illness studies (COIs) for BD published 2012 or later and (3) assess the quality of the identified studies. Methods A systematic search was conducted in MedLine, EMBASE and PsycINFO. For both EEs and COIs, quality assessments were conducted and general and methodological characteristics of the studies were extracted. Outcomes included incremental-cost-effectiveness ratios for EEs and direct and indirect costs for COIs. Results Eight EEs and ten COIs were identified. The included studies revealed high heterogeneity in general and methodological characteristics and study quality. All interventions resulted in improved clinical outcomes. Five studies additionally concluded decreased total costs. For COIs, we found a wide range of direct ($881-$27,617) and indirect cost estimates per capita per year ($1,568-$116,062). Limitations High heterogeneity in terms of interventions, study design and outcomes made it difficult to compare results across studies. Conclusions Interventions improved clinical outcomes in all studies and led to cost-savings in five studies. Findings suggest that non-pharmacological intervention for BD might be cost-effective. Studies on the costs of BD revealed that BD has a substantial economic burden. However, we also found that the number of EEs was relatively low and methodology was heterogenous and therefore encourage future research to widen the body of knowledge in this research field and use standardized methodology.
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http://dx.doi.org/10.1016/j.jad.2020.06.064DOI Listing
November 2020

Cost-Effectiveness of Virtual Reality Cognitive Behavioral Therapy for Psychosis: Health-Economic Evaluation Within a Randomized Controlled Trial.

J Med Internet Res 2020 05 5;22(5):e17098. Epub 2020 May 5.

Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, Netherlands.

Background: Evidence was found for the effectiveness of virtual reality-based cognitive behavioral therapy (VR-CBT) for treating paranoia in psychosis, but health-economic evaluations are lacking.

Objective: This study aimed to determine the short-term cost-effectiveness of VR-CBT.

Methods: The health-economic evaluation was embedded in a randomized controlled trial evaluating VR-CBT in 116 patients with a psychotic disorder suffering from paranoid ideation. The control group (n=58) received treatment as usual (TAU) for psychotic disorders in accordance with the clinical guidelines. The experimental group (n=58) received TAU complemented with add-on VR-CBT to reduce paranoid ideation and social avoidance. Data were collected at baseline and at 3 and 6 months postbaseline. Treatment response was defined as a pre-post improvement of symptoms of at least 20% in social participation measures. Change in quality-adjusted life years (QALYs) was estimated by using Sanderson et al's conversion factor to map a change in the standardized mean difference of Green's Paranoid Thoughts Scale score on a corresponding change in utility. The incremental cost-effectiveness ratios were calculated using 5000 bootstraps of seemingly unrelated regression equations of costs and effects. The cost-effectiveness acceptability curves were graphed for the costs per treatment responder gained and per QALY gained.

Results: The average mean incremental costs for a treatment responder on social participation ranged between €8079 and €19,525, with 90.74%-99.74% showing improvement. The average incremental cost per QALY was €48,868 over the 6 months of follow-up, with 99.98% showing improved QALYs. Sensitivity analyses show costs to be lower when relevant baseline differences were included in the analysis. Average costs per treatment responder now ranged between €6800 and €16,597, while the average cost per QALY gained was €42,030.

Conclusions: This study demonstrates that offering VR-CBT to patients with paranoid delusions is an economically viable approach toward improving patients' health in a cost-effective manner. Long-term effects need further research.

Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 12929657; http://www.isrctn.com/ISRCTN12929657.
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http://dx.doi.org/10.2196/17098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238085PMC
May 2020

Cost and Effectiveness of Blended Versus Standard Cognitive Behavioral Therapy for Outpatients With Depression in Routine Specialized Mental Health Care: Pilot Randomized Controlled Trial.

J Med Internet Res 2019 10 29;21(10):e14261. Epub 2019 Oct 29.

Department of Clinical, Neuro and Developmental Psychology, Clinical Psychology Section, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.

Background: Cognitive behavioral therapy (CBT) is an effective treatment, but access is often restricted due to costs and limited availability of trained therapists. Blending online and face-to-face CBT for depression might improve cost-effectiveness and treatment availability.

Objective: This pilot study aimed to examine the costs and effectiveness of blended CBT compared with standard CBT for depressed patients in specialized mental health care to guide further research and development of blended CBT.

Methods: Patients were randomly allocated to blended CBT (n=53) or standard CBT (n=49). Blended CBT consisted of 10 weekly face-to-face sessions and 9 Web-based sessions. Standard CBT consisted of 15 to 20 weekly face-to-face sessions. At baseline and 10, 20, and 30 weeks after start of treatment, self-assessed depression severity, quality-adjusted life-years (QALYs), and costs were measured. Clinicians, blinded to treatment allocation, assessed psychopathology at all time points. Data were analyzed using linear mixed models. Uncertainty intervals around cost and effect estimates were estimated with 5000 Monte Carlo simulations.

Results: Blended CBT treatment duration was mean 19.0 (SD 12.6) weeks versus mean 33.2 (SD 23.0) weeks in standard CBT (P<.001). No significant differences were found between groups for depressive episodes (risk difference [RD] 0.06, 95% CI -0.05 to 0.19), response to treatment (RD 0.03, 95% CI -0.10 to 0.15), and QALYs (mean difference 0.01, 95% CI -0.03 to 0.04). Mean societal costs for blended CBT were €1183 higher than standard CBT. This difference was not significant (95% CI -399 to 2765). Blended CBT had a probability of being cost-effective compared with standard CBT of 0.02 per extra QALY and 0.37 for an additional treatment response, at a ceiling ratio of €25,000. For health care providers, mean costs for blended CBT were €176 lower than standard CBT. This difference was not significant (95% CI -659 to 343). At €0 per additional unit of effect, the probability of blended CBT being cost-effective compared with standard CBT was 0.75. The probability increased to 0.88 at a ceiling ratio of €5000 for an added treatment response, and to 0.85 at €10,000 per QALY gained. For avoiding new depressive episodes, blended CBT was deemed not cost-effective compared with standard CBT because the increase in costs was associated with negative effects.

Conclusions: This pilot study shows that blended CBT might be a promising way to engage depressed patients in specialized mental health care. Compared with standard CBT, blended CBT was not considered cost-effective from a societal perspective but had an acceptable probability of being cost-effective from the health care provider perspective. Results should be carefully interpreted due to the small sample size. Further research in larger replication studies focused on optimizing the clinical effects of blended CBT and its budget impact is warranted.

Trial Registration: Netherlands Trial Register NTR4650; https://www.trialregister.nl/trial/4408.

International Registered Report Identifier (irrid): RR2-10.1186/s12888-014-0290-z.
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http://dx.doi.org/10.2196/14261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914243PMC
October 2019

Implementing interventions to reduce work-related stress among health-care workers: an investment appraisal from the employer's perspective.

Int Arch Occup Environ Health 2020 01 26;93(1):123-132. Epub 2019 Aug 26.

Centre for Economic Evaluation, Trimbos-Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands.

Purpose: The [email protected] implementation strategy has been demonstrated to be successful in reducing stress in employees. Now, we assess the economic return-on-investment to see if it would make for a favourable business case for employers.

Methods: Data were collected from 303 health-care workers assigned to either a waitlisted control condition (142 employees in 15 teams) or to [email protected] (161 employees in 15 teams). Main outcome was productivity losses measured using the Trimbos and iMTA Cost questionnaire in Psychiatry. Measurements were taken at baseline, 6, and 12 months post-baseline.

Results: The per-employee costs of the strategy were €50. Net monetary benefits were the benefits (i.e., improved productivity) minus the costs (i.e., intervention costs) and were the main outcome of this investment appraisal. Per-employee net benefits amounted to €2981 on average, which was an almost 60-fold payout of the initial investment of €50. There was a 96.7% likelihood for the modest investment of €50 to be offset by cost savings within 1 year. Moreover, a net benefit of at least €1000 still has a likelihood of 88.2%.

Conclusions: In general, there was a high likelihood that [email protected] offers an appealing business case from the perspective of employers, but the employer should factor in the additional per-employee costs of the stress-reducing interventions. Still, if these additional costs were as high as €2981, then costs and benefits would break even. This study was registered in the Netherlands National Trial Register, trial code: NTR5527.
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http://dx.doi.org/10.1007/s00420-019-01471-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989605PMC
January 2020

Designing and Testing of a Health-Economic Markov Model for Prevention and Treatment of Early Psychosis.

Expert Rev Pharmacoecon Outcomes Res 2020 Jun 20;20(3):269-279. Epub 2019 Jun 20.

Centre of Economic Evaluation (Trimbos Institute), Netherlands Institute of Mental Health and Addiction , Utrecht, The Netherlands.

Background: This study aims to report on the design of a model to determine the cost-effectiveness of prevention and treatment of early psychosis (PsyMod) and to estimate ten-year cost-effectiveness and budget impact of interventions targeting individuals with ultra-high risk (UHR) of developing psychosis or with first episode psychosis (FEP).

Methods: PsyMod was built in parallel with the development of a new standard of care for treatment of early psychosis in the Netherlands. PsyMod is a state-transition cohort simulation model and considers six health states, namely ultra-high risk of psychosis (UHR), FEP, post-FEP, no-UHR, recovery/remission, and death. Results are expressed as total healthcare costs, QALYs, incremental cost-effectiveness ratio (ICER), and budget impact.

Results: PsyMod was used to extrapolate budget impact and cost-effectiveness of cognitive behavioural therapy for preventing FEP for individuals at UHR of psychosis (CBTuhr) compared to care as usual. CBTuhr resulted in a per-patient increase of 0.06 QALYs and a per patient cost reduction of €654 (dominant ICER) with a reduction in 5-year healthcare costs of €1,002,166.

Conclusions: PsyMod can be used to examine cost-effectiveness and budget impact of interventions targeting prevention and treatment of FEP and is freely available for academic purposes upon request by the authors.
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http://dx.doi.org/10.1080/14737167.2019.1632194DOI Listing
June 2020

Cost-effectiveness, cost-utility and the budget impact of antidepressants versus preventive cognitive therapy with or without tapering of antidepressants.

BJPsych Open 2019 Jan;5(1):e12

Professor of Clinical Psychology in Psychiatry,Amsterdam UMC, location AMC,Department of Psychiatry,University of Amsterdam,the Netherlands.

Background: As depression has a recurrent course, relapse and recurrence prevention is essential.AimsIn our randomised controlled trial (registered with the Nederlands trial register, identifier: NTR1907), we found that adding preventive cognitive therapy (PCT) to maintenance antidepressants (PCT+AD) yielded substantial protective effects versus antidepressants only in individuals with recurrent depression. Antidepressants were not superior to PCT while tapering antidepressants (PCT/-AD). To inform decision-makers on treatment allocation, we present the corresponding cost-effectiveness, cost-utility and budget impact.

Method: Data were analysed (n = 289) using a societal perspective with 24-months of follow-up, with depression-free days and quality-adjusted life years (QALYs) as health outcomes. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were derived to provide information about cost-effectiveness. The budget impact was examined with a health economic simulation model.

Results: Mean total costs over 24 months were €6814, €10 264 and €13 282 for AD+PCT, antidepressants only and PCT/-AD, respectively. Compared with antidepressants only, PCT+AD resulted in significant improvements in depression-free days but not QALYs. Health gains did not significantly favour antidepressants only versus PCT/-AD. High probabilities were found that PCT+AD versus antidepressants only and antidepressants only versus PCT/-AD were dominant with low willingness-to-pay thresholds. The budget impact analysis showed decreased societal costs for PCT+AD versus antidepressants only and for antidepressants only versus PCT/-AD.

Conclusions: Adding PCT to antidepressants is cost-effective over 24 months and PCT with guided tapering of antidepressants in long-term users might result in extra costs. Future studies examining costs and effects of antidepressants versus psychological interventions over a longer period may identify a break-even point where PCT/-AD will become cost-effective.Declaration of interestC.L.H.B. is co-editor of PLOS One and receives no honorarium for this role. She is also co-developer of the Dutch multidisciplinary clinical guideline for anxiety and depression, for which she receives no remuneration. She is a member of the scientific advisory board of the National Insure Institute, for which she receives an honorarium, although this role has no direct relation to this study. C.L.H.B. has presented keynote addresses at conferences, such as the European Psychiatry Association and the European Conference Association, for which she sometimes receives an honorarium. She has presented clinical training workshops, some including a fee. She receives royalties from her books and co-edited books and she developed preventive cognitive therapy on the basis of the cognitive model of A. T. Beck. W.A.N. has received grants from the Netherlands Organisation for Health Research and Development and the European Union and honoraria and speakers' fees from Lundbeck and Aristo Pharma, and has served as a consultant for Daleco Pharma.
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http://dx.doi.org/10.1192/bjo.2018.81DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381417PMC
January 2019

Health-economic benefits of treating trauma in psychosis.

Eur J Psychotraumatol 2019 21;10(1):1565032. Epub 2019 Jan 21.

Behavioural Science Institute, Radboud University Nijmegen, NijCare, Nijmegen, The Netherlands.

: Co-occurrence of posttraumatic stress disorder (PTSD) in psychosis (estimated as 12%) raises personal suffering and societal costs. Health-economic studies on PTSD treatments in patients with a diagnosis of a psychotic disorder have not yet been conducted, but are needed for guideline development and implementation. This study aims to analyse the cost-effectiveness of guideline PTSD therapies in patients with a psychotic disorder. : This health-economic evaluation alongside a randomized controlled trial included 155 patients with a psychotic disorder in care as usual (CAU), with comorbid PTSD. Participants received eye movement desensitization and reprocessing (EMDR) ( = 55), prolonged exposure (PE) ( = 53) or waiting list (WL) ( = 47) with masked assessments at baseline (T0) and at the two-month (post-treatment, T2) and six-month follow-up (T6). Costs were calculated using the TiC-P interview for assessing healthcare consumption and productivity losses. Incremental cost-effectiveness ratios and economic acceptability were calculated for quality-adjusted life years (EQ-5D-3L-based QALYs) and PTSD 'Loss of diagnosis' (LoD, CAPS). : Compared to WL, costs were lower in EMDR (-€1410) and PE (-€501) per patient per six months. In addition, EMDR (robust SE 0.024, = 2.14, = .035) and PE (robust SE 0.024, = 2.14, = .035) yielded a 0.052 and 0.051 incremental QALY gain, respectively, as well as 26% greater probability for LoD following EMDR (robust SE = 0.096, = 2.66, = .008) and 22% following PE (robust SE 0.098, = 2.28, = .023). Acceptability curves indicate high probabilities of PTSD treatments being the better economic choice. Sensitivity analyses corroborated these outcomes. : Adding PTSD treatment to CAU for individuals with psychosis and PTSD seem to yield better health and less PTSD at lower costs, which argues for implementation.
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http://dx.doi.org/10.1080/20008198.2018.1565032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6346719PMC
January 2019

A discrete-choice experiment to assess treatment modality preferences of patients with depression.

J Med Econ 2019 Feb 22;22(2):178-186. Epub 2018 Dec 22.

c Department of Health Services Research , CAPHRI Care and Public Health Research Institute, Maastricht University , The Netherlands.

Aims: There is an increasing interest in understanding patients' preferences in the area of healthcare decision-making to better match treatment with patients' preferences and improve treatment uptake and adherence. The aim of this study was to elicit the preferences of patients with a depressive disorder regarding treatment modalities.

Materials And Methods: In a discrete-choice experiment, patients chose repetitively between two hypothetical depression treatments that varied in four treatment attributes: waiting time until the start of treatment, treatment intensity, level of digitalization, and group size. A Bayesian-efficient design was used to develop 12 choice sets, and patients' preferences and preference variation was estimated using a random parameters logit model.

Results: A total of 165 patients with depression completed the survey. Patients preferred short (over long) waiting times, face-to-face (over digital) treatment, individual (over group) treatment, and one session per week over two sessions per week or one session per 2 weeks. Patients disfavoured digital treatment and treatment in a large group. Waiting time and treatment intensity were substantially less important attributes to patients than face-to-face (vs digital) and group size. Significant variation in preferences was observed for each attribute, and sub-group analyses revealed that these differences were in part related to education.

Limitations: The convenience sample over-represented the female and younger population, limiting generalizability. Limited information on background characteristics limited the possibilities to explore preference heterogeneity.

Conclusion: This study demonstrated how different treatment components for depression affect patients' preferences for those treatments. There is significant variation in treatment preferences, even after accounting for education. Incorporating individual patients' preferences into treatment decisions could potentially lead to improved adherence of treatments for depressive disorders.
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http://dx.doi.org/10.1080/13696998.2018.1555404DOI Listing
February 2019

A discrete-choice experiment to assess treatment modality preferences of patients with anxiety disorder.

J Med Econ 2019 Feb 22;22(2):169-177. Epub 2018 Dec 22.

c Department of Health Services Research , CAPHRI Care and Public Health Research Institute, Maastricht University , Maastricht , The Netherlands.

Aims: The aim of this study was to elicit the preference of patients with an anxiety disorder regarding treatment modalities. Understanding patients' preferences could help optimize treatment uptake and adherence to therapeutic interventions.

Materials And Methods: A discrete-choice experiment was used to elicit patients' preferences with regard to four treatment characteristics: waiting time until first treatment, intensity of treatment, face-to-face vs digital treatment, and group size. In 12 choice sets, participants were asked to choose between two treatment alternatives. A random parameters logit model was used to analyse the data.

Results: A total of 126 participants, aged 18 years and older, currently or in the previous year in treatment for an anxiety disorder, completed the survey. Respondents preferred short (over long) waiting times, face-to-face (over digital) treatment, individual (over group) treatment and a treatment intensity of one session per week rather than two sessions per week or one session every two weeks. Waiting time and treatment intensity were substantially less important to patients than level of digitalization and group size. Heterogeneity in preference was significant for each attribute, and sub-group analyses revealed this was partly related to education level and age.

Limitations: The convenience sample over-represented the female and younger population, limiting generalizability. Limited information on background characteristics limited the possibilities to explore preference heterogeneity.

Conclusions: This study demonstrated how different treatment components for anxiety disorders affect patients' preferences for those treatments. There is significant variation in treatment preferences, even after accounting for age and education. Incorporating patients' preferences into treatment decisions could potentially lead to improved adherence of treatments for anxiety disorders.
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http://dx.doi.org/10.1080/13696998.2018.1555403DOI Listing
February 2019

Value of information analysis of an early intervention for subthreshold panic disorder: Healthcare versus societal perspective.

PLoS One 2018 7;13(11):e0205876. Epub 2018 Nov 7.

Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.

Background: Panic disorder is associated with high productivity costs. These costs, which should be included in cost-effectiveness analyses (CEA) from a societal perspective, have a considerable impact on cost-effectiveness estimates. However, they are often omitted in published CEAs. It is therefore uncertain whether choosing a societal perspective changes priority setting in future research as compared to a healthcare perspective.

Objectives: To identify research priorities regarding the cost-effectiveness of an early intervention for subthreshold panic disorder using value of information (VOI) analysis and to investigate to what extent priority setting depends on the perspective.

Methods: We calculated the cost-effectiveness of an early intervention for panic disorder from a healthcare perspective and a societal perspective. We performed a VOI analysis, which estimates the expected value of eliminating the uncertainty surrounding cost-effectiveness estimates, for both perspectives.

Results: From a healthcare perspective the early intervention was more effective at higher costs compared to usual care (€17,144 per QALY), whereas it was cost-saving from a societal perspective. Additional research to eliminate parameter uncertainty was valued at €129.7 million from a healthcare perspective and €29.5 million from a societal perspective. Additional research on the early intervention utility gain was most valuable from a healthcare perspective, whereas from a societal perspective additional research would generate little added value.

Conclusions: Priority setting for future research differed substantially according to the perspective. Our study underlines that the health-economic perspective of CEAs on interventions for panic disorder must be chosen carefully in order to avoid inappropriate choices in research priorities.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205876PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6221282PMC
April 2019

Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review.

PLoS One 2018 15;13(10):e0205278. Epub 2018 Oct 15.

Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: In primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies.

Methods: We searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality.

Results: A total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes.

Conclusion: This review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions.

Registration: Study methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205278PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188754PMC
March 2019

Early intervention for subthreshold panic disorder in the Netherlands: A model-based economic evaluation from a societal perspective.

PLoS One 2018 21;13(2):e0193338. Epub 2018 Feb 21.

Centre of Economic Evaluation, Trimbos Institute (Netherlands Institute for Mental Health and Addiction), Utrecht, The Netherlands.

Background: Panic disorder (PD) is associated with impaired functioning and reduced quality of life. In the Netherlands, almost 2% of the population experiences clinically relevant panic symptoms without meeting the diagnostic criteria for PD, which is referred to as subthreshold PD (STHPD). Evidence suggests that subthreshold mental disorders may have a similar impact on quality of life and functioning in comparison with full-blown mental disorders, which draws attention to the need for interventions for STHPD. These interventions are currently not systematically provided in clinical practice. This study aims to investigate the population cost-effectiveness of adding a CBT-based early intervention for adults with STHPD to the existing health care for people with PD in the Netherlands.

Methods: A health-economic Markov model was constructed in order to compare quality adjusted life-years (QALYs) and societal costs of adding an early intervention to usual care for PD. The model compares usual care with an alternative program in which usual care is supplemented with a CBT-based early intervention. Input parameters for the model were derived from national sources and published literature where possible, and based on expert opinion otherwise. Probabilistic and deterministic sensitivity analyses were conducted to evaluate the uncertainty of the model input parameters.

Results: On average, the added CBT-based early intervention was dominant in comparison with usual care, meaning that the early intervention yielded more QALYs at lower costs. At a willingness-to-pay threshold of €20,000 per QALY, the cost-effectiveness probability of the added early intervention was 98%. Sensitivity analyses showed that the results were robust.

Conclusions: This study showed that offering an early intervention in addition to usual care for PD is potentially cost-effective, but it should be further investigated to what extent trial results can be extrapolated to the level of the population before such interventions are implemented on a large scale.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193338PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821393PMC
May 2018

A Cost-Effectiveness Analysis to Evaluate a System Change in Mental Healthcare in the Netherlands for Patients with Depression or Anxiety.

Adm Policy Ment Health 2018 07;45(4):530-537

Pro Persona Research, Pro Persona, Wolfheze, The Netherlands.

Over the last decade, the Dutch mental healthcare system has been subject to profound policy reforms, in order to achieve affordable, accessible, and high quality care. One of the adjustments was to substitute part of the specialized care for general mental healthcare. Using a quasi-experimental design, we compared the cost-effectiveness of patients in the new setting with comparable patients from specialized mental healthcare in the old setting. Results showed that for this group of patients the average cost of treatment was significantly reduced by, on average, €2132 (p < 0.001), with similar health outcomes as in the old system.
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http://dx.doi.org/10.1007/s10488-017-0842-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999158PMC
July 2018

A Systematic Review and Critical Appraisal of Economic Evaluations of Pharmacological Interventions for People with Bipolar Disorder.

Pharmacoeconomics 2017 03;35(3):271-296

Centre of Economic Evaluation, Trimbos Institute (The Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands.

Background: Bipolar disorder (BD) is a chronic mood disorder that causes substantial psychological and financial burden. Various pharmacological treatments are effective in the management and prevention of acute episodes of BD. In an era of tighter healthcare budgets and a need for more efficient use of resources, several economic evaluations have evaluated the cost effectiveness of treatments for BD.

Objective: The aim of this study was to systematically review and appraise published economic evaluations of pharmacological interventions for BD.

Methods: A systematic search combining search terms specific to BD with a health economics search filter was conducted on six bibliographic databases (EMBASE, MEDLINE, PsycINFO, HTA, NHS EED, CENTRAL) in order to identify trial- or model-based full economic evaluations of pharmacological treatments of any phase of the disorder that were published between 1 January 1990 and 18 December 2015. Studies that met the inclusion criteria were critically appraised using the Quality of Health Economic Studies (QHES) checklist, and synthesised in a narrative way.

Results: The review included 19 economic studies, which varied with regard to the type and number of interventions assessed, the study design, the phase of treatment (acute or maintenance), the source of efficacy data and the method for evidence synthesis, the outcome measures, the time horizon and the countries/settings in which the studies were conducted. The study quality was variable but the majority of studies were of high or fair quality.

Conclusion: Pharmacological interventions are cost effective, compared with no treatment, in the management of BD, both in the acute and maintenance phases. However, it is difficult to draw safe conclusions on the relative cost effectiveness between drugs due to differences across studies and limitations characterising many of them. Future economic evaluations need to consider the whole range of treatment options available for the management of BD and adopt appropriate methods for evidence synthesis and economic modelling, to explore more robustly the relative cost effectiveness of pharmacological interventions for people with BD.
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http://dx.doi.org/10.1007/s40273-016-0473-1DOI Listing
March 2017

Cost-effectiveness of interventions for treating anxiety disorders: A systematic review.

J Affect Disord 2017 Mar 13;210:1-13. Epub 2016 Dec 13.

Centre of Economic Evaluation, Trimbos Institute, Netherlands Institute for Mental Health and Addiction, Utrecht, The Netherlands; Department of Health Services Research, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands. Electronic address:

Background: Anxiety disorders are highly prevalent mental disorders that constitute a major burden on patients and society. As a consequence, economic evaluations of the interventions have become increasingly important. However, no recent overview of these economic evaluations is currently available and the quality of the published economic evaluations has not yet been assessed. Therefore, the current study has two aims: to provide an overview of the evidence regarding the cost-effectiveness of interventions for anxiety disorders, and to assess the quality of the studies identified.

Methods: A systematic review was conducted using PubMed, PsycINFO, NHS-EED, and the CEA registry. We included full economic evaluations on interventions for all anxiety disorders published before April 2016, with no restrictions on study populations and comparators. Preventive interventions were excluded. Study characteristics and cost-effectiveness data were collected. The quality of the studies was appraised using the Consensus on Health Economic Criteria.

Results: Forty-two out of 826 identified studies met the inclusion criteria. The studies were heterogeneous and the quality was variable. Internet-delivered cognitive behavioural therapy (iCBT) appeared to be cost-effective in comparison with the control conditions. Four out of five studies comparing psychological interventions with pharmacological interventions showed that psychological interventions were more cost-effective than pharmacotherapy.

Limitations: Comparability was limited by heterogeneity in terms of interventions, study design, outcome and study quality.

Conclusions: Forty-two studies reporting cost-effectiveness of interventions for anxiety disorders were identified. iCBT was cost-effective in comparison with the control conditions. Psychological interventions for anxiety disorders might be more cost-effective than pharmacological interventions.
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http://dx.doi.org/10.1016/j.jad.2016.12.005DOI Listing
March 2017

Four-Year Cost-effectiveness of Cognitive Behavior Therapy for Preventing First-episode Psychosis: The Dutch Early Detection Intervention Evaluation (EDIE-NL) Trial.

Schizophr Bull 2017 03;43(2):365-374

Department of Psychosis Research, Parnassia Psychiatric Institute, The Hague, The Netherlands.

Background: This study aims to evaluate the long-term cost-effectiveness of add-on cognitive behavior therapy (CBT) for the prevention of psychosis for individuals at ultrahigh risk (UHR) of psychosis.

Method: The Dutch Early Detection and Intervention randomized controlled trial was used, comparing routine care (RC; n = 101) with routine care plus CBT for UHR (here called CBTuhr; n = 95). A cost-effectiveness analysis was conducted with treatment response (defined as proportion of averted transitions to psychosis) as an outcome and a cost-utility analysis with quality-adjusted life years (QALYs) gained as a secondary outcome.

Results: The proportion of averted transitions to psychosis was significantly higher in the CBTuhr condition (with a risk difference of 0.122; b = 1.324, SEb = 0.017, z = 7.99, P < 0.001). CBTuhr showed an 83% probability of being more effective and less costly than RC by -US$ 5777 (savings) per participant. In addition, over the 4-year follow-up period, cumulative QALY health gains were marginally (but not significantly) higher in CBTuhr than for RC (2.63 vs. 2.46) and the CBTuhr intervention had a 75% probability of being the superior treatment (more QALY gains at lower costs) and a 92% probability of being cost-effective compared with RC at the Dutch threshold value (US$ 24 560; €20 000 per QALY).

Conclusions: Add-on preventive CBTuhr had a high likelihood (83%) of resulting in more averted transitions to psychosis and lower costs as compared with RC. In addition, the intervention had a high likelihood (75%) of resulting in more QALY gains and lower costs as compared to RC.
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http://dx.doi.org/10.1093/schbul/sbw084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605258PMC
March 2017

Blended vs. face-to-face cognitive behavioural treatment for major depression in specialized mental health care: study protocol of a randomized controlled cost-effectiveness trial.

BMC Psychiatry 2014 Oct 18;14:290. Epub 2014 Oct 18.

Faculty of Psychology and Education, Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, BT, 1081, Amsterdam, the Netherlands.

Background: Depression is a prevalent disorder, associated with a high disease burden and substantial societal, economic and personal costs. Cognitive behavioural treatment has been shown to provide adequate treatment for depression. By offering this treatment in a blended format, in which online and face-to-face treatment are combined, it might be possible to reduce the number of costly face-to-face sessions required to deliver the treatment protocol. This could improve the cost-effectiveness of treatment, while maintaining clinical effects. This protocol describes the design of a pilot study for the evaluation of the feasibility, acceptability and cost-effectiveness of blended cognitive behavioural therapy for patients with major depressive disorder in specialized outpatient mental health care.

Methods/design: In a randomized controlled trial design, adult patients with major depressive disorder are allocated to either blended cognitive behavioural treatment or traditional face-to-face cognitive behavioural treatment (treatment as usual). We aim to recruit one hundred and fifty patients. Blended treatment will consist of ten face-to-face and nine online sessions provided alternately on a weekly basis. Traditional cognitive behavioural treatment will consist of twenty weekly sessions. Costs and effects are measured at baseline and after 10, 20 and 30 weeks. Evaluations are directed at cost-effectiveness (with depression severity and diagnostic status as outcomes), and cost-utility (with costs per quality adjusted life year, QALY, as outcome). Costs will encompass health care uptake costs and productivity losses due to absence from work and lower levels of efficiency while at work. Other measures of interest are mastery, working alliance, treatment preference at baseline, depressive cognitions, treatment satisfaction and system usability.

Discussion: The results of this pilot study will provide an initial insight into the feasibility and acceptability of blended cognitive behavioural treatment in terms of clinical and economic outcomes (proof of concept) in routine specialized mental health care settings, and an indication as to whether a well-powered clinical trial of blended cognitive behavioural treatment for depression in routine practice would be advisable. This will be determined based on the perspective of various stakeholders including patients, mental health service providers and health insurers. Strengths and limitations of the study are discussed.

Trial Registration: Netherlands Trial Register NTR4650 . Registered 18 June 2014.
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http://dx.doi.org/10.1186/s12888-014-0290-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209039PMC
October 2014

Mental health care system optimization from a health-economics perspective: where to sow and where to reap?

J Ment Health Policy Econ 2014 Jun;17(2):51-60

Da Costakade 45, 3521 VS, Utrecht, The Netherlands,

Background: Health care expenditure (as % of GDP) has been rising in all OECD countries over the last decades. Now, in the context of the economic downturn, there is an even more pressing need to better guarantee the sustainability of health care systems. This requires that policy makers are informed about optimal allocation of budgets. We take the Dutch mental health system in the primary care setting as an example of new ways to approach optimal allocation.

Aims Of The Study: To demonstrate how health economic modelling can help in identifying opportunities to improve the Dutch mental health care system for patients presenting at their GP with symptoms of anxiety, stress, symptoms of depression, alcohol abuse/dependence, anxiety disorder or depressive disorder such that changes in the health care system have the biggest leverage in terms of improved cost-effectiveness. Investigating such scenarios may serve as a starting point for setting an agenda for innovative and sustainable health care policies.

Methods: A health economic simulation model was used to synthesize clinical and economic evidence. The model was populated with data from GPs' national register on the diagnosis, treatment, referral and prescription of their patients in the year 2009. A series of `what-if' analyses was conducted to see what parameters (uptake, adherence, effectiveness and the costs of the interventions) are associated with the most substantial impact on the cost-effectiveness of the health care system overall.

Results: In terms of improving the overall cost-effectiveness of the primary mental health care system, substantial benefits could be derived from increasing uptake of psycho-education by GPs for patients presenting with stress and when low cost interventions are made available that help to increase the patients' compliance with pharmaceutical interventions, particularly in patients presenting with symptoms of anxiety. In terms of intervention costs, decreasing the costs of antidepressants is expected to yield the biggest impact on the cost-effectiveness of the primary mental health care system as a whole. These "target group -- intervention" combinations are the most appealing candidates for system innovation from a cost-effectiveness point of view, but need to be carefully aligned with other considerations such as equity, acceptability, appropriateness, feasibility and strength of evidence.

Discussion And Limitations: The study has some strengths and limitations. Cost-effectiveness analysis is performed using a health economic model that is based on registration data from a sample of GPs, but assumptions had to be made on how these data could be extrapolated to all GPs. Parameters on compliance rates were obtained from a focus group or were based on mere assumptions, while the clinical effectiveness of interventions were taken from meta-analyses or randomised trials. Effectiveness is expressed in terms of years lived with disability (YLD) averted; indirect benefits such as reduction of lost productivity or lesser pressure on informal caregivers are not taken into account. Whenever assumptions had to be made, we opted for conservative estimates that are unlikely to have resulted in an overly optimistic portrayal of the cost-effectiveness ratios.

Implications For Health Care Provision And Use: The model can be used to guide health care system innovation, by identifying those parameters where changes in the uptake, compliance, effectiveness and costs of interventions have the largest impact on the cost-effectiveness of a mental health care system overall. In this sense, the model could assist policy makers during the first stage of decision making on where to make improvements in the health care system, or assist the process of guideline development. However, the improvement candidates need to be assessed during a second-stage 'normative filter', to address considerations other than cost-effectiveness.
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June 2014

Improving the cost-effectiveness of a healthcare system for depressive disorders by implementing telemedicine: a health economic modeling study.

Am J Geriatr Psychiatry 2014 Mar 4;22(3):253-62. Epub 2013 Jun 4.

Trimbos Institute (The Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands; Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.

Objectives: Depressive disorders are significant causes of disease burden and are associated with substantial economic costs. It is therefore important to design a healthcare system that can effectively manage depression at sustainable costs. This article computes the benefit-to-cost ratio of the current Dutch healthcare system for depression, and investigates whether offering more online preventive interventions improves the cost-effectiveness overall.

Methods: A health economic (Markov) model was used to synthesize clinical and economic evidence and to compute population-level costs and effects of interventions. The model compared a base case scenario without preventive telemedicine and alternative scenarios with preventive telemedicine. The central outcome was the benefit-to-cost ratio, also known as return-on-investment (ROI).

Results: In terms of ROI, a healthcare system with preventive telemedicine for depressive disorders offers better value for money than a healthcare system without Internet-based prevention. Overall, the ROI increases from €1.45 ($1.72) in the base case scenario to €1.76 ($2.09) in the alternative scenario in which preventive telemedicine is offered. In a scenario in which the costs of offering preventive telemedicine are balanced by reducing the expenditures for curative interventions, ROI increases to €1.77 ($2.10), while keeping the healthcare budget constant.

Conclusions: For a healthcare system for depressive disorders to remain economically sustainable, its cost-benefit ratio needs to be improved. Offering preventive telemedicine at a large scale is likely to introduce such an improvement.
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http://dx.doi.org/10.1016/j.jagp.2013.01.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4096928PMC
March 2014

Non-fatal burden of disease due to mental disorders in the Netherlands.

Soc Psychiatry Psychiatr Epidemiol 2013 Oct 10;48(10):1591-9. Epub 2013 Feb 10.

Trimbos Institute (Netherlands Institute of Mental Health and Addiction), P.O. Box 724, 3500 AS, Utrecht, The Netherlands,

Purpose: To estimate the disease burden due to 15 mental disorders at both individual and population level.

Methods: Using a population-based survey (NEMESIS, N = 7,056) the number of years lived with disability per one million population were assessed. This was done with and without adjustment for comorbidity.

Results: At individual level, major depression, dysthymia, bipolar disorder, panic disorder, social phobia, eating disorder and schizophrenia are the disorders most markedly associated with health-related quality of life decrement. However, at population level, the number of affected people and the amount of time spent in an adverse health state become strong drivers of population ill-health. Simple phobia, social phobia, depression, dysthymia and alcohol dependence emerged as public health priorities.

Conclusions: From a clinical perspective, we tend to give priority to the disorders that exact a heavy toll on individuals. This puts the spotlight on disorders such as bipolar disorder and schizophrenia. However, from a public health perspective, disorders such as simple phobia, social phobia and dysthymia--which are highly prevalent and tend to run a chronic course--are identified as leading causes of population ill-health, and thus, emerge as public health priorities.
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http://dx.doi.org/10.1007/s00127-013-0660-8DOI Listing
October 2013
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