Estudio de costo-efectividad del tratamiento de la depresión en México / Cost-effectiveness study of depression management in Mexico

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 <cost-effective>> labeled WHO-CHOICE (CHOosing interventions that are Cost-Effective). This paper presents the findings of the evaluation of cost-effectiveness 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 207,1 71, and with SSRI of 21 7,568, corresponding to more than double of DALYs when tricyclic anti-depressants 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 cost-effectiveness 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 <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.

RESUMEN

Introducción La depresión es un problema de salud pública que conlleva costos importantes para el individuo y la sociedad. Con la finalidad de establecer prioridades basadas en evidencias para la asignación de recursos en el cuidado de la salud mental, es necesario integrar los costos y la efectividad de las intervenciones y especificar los paquetes esenciales para su tratamiento. En esta dirección, la Organización Mundial de la Salud convocó al Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, como centro colaborador, a participar en el proyecto <sus siglas en inglés CHOosing Interventions that are Cost-Effective). El presente texto presenta los hallazgos del estudio de relación costo-efectividad de diferentes intervenciones clínicas para el tratamiento de la depresión en México, considerando su implantación en los servicios de atención primaria a la salud. Método La unidad de medición de costo-efectividad seleccionada por la OMS (y utilizada en este trabajo) son los Años de vida ajustados por discapacidad a causa de alguna enfermedad (AVISA perdidos, en inglés DALYs, Disability Adjusted Life Years), que resultan de la suma de los años que se pierden por mortalidad prematura más los años que se pierden por vivir en una situación de discapacidad. Las intervenciones evaluadas fueron 1. antidepresivos tricíclicos; 2. antidepresivos nuevos (ISRS); 3. psicoterapia breve; 4. antidepresivos tricíclicos + psicoterapia breve; 5. antidepresivos nuevos + psicoterapia breve; 6. antidepresivos tricíclicos + psicoterapia breve + manejo proactivo de caso; y 7. antidepresivos nuevos + psicoterapia breve + manejo proactivo de caso. Para determinar su efectividad, se calcularon los AVISAs perdidos que se evitan como resultado de cada intervención. Se incluyeron los costos del paciente y los del programa, un descuento de 3% por el proceso de convertir valores futuros a presentes, así como un ajuste por edad, otorgando menos peso a los años vividos por los jóvenes. Finalmente, para determinar la relación costo-efectividad, se calculó el costo por cada AVISA evitado con cada intervención. Resultados Las estrategias combinadas de manejo proactivo de caso con psicoterapia breve más antidepresivos pueden considerarse como las más eficaces. Con la combinación con antidepresivos tricíclicos, el número de AVISAs evitados fue de 207171, y con la de ISRS fue de 217568, lo que corresponde a más del doble de AVISAs cuando se emplean únicamente antidepresivos tricíclicos, y casi al doble cuando se emplean únicamente ISRS. La intervención más costosa fue la combinación de ISRS con psicoterapia breve, con un monto total de $12,256 millones de pesos (972 millones de dólares), y la menos costosa fue el tratamiento con antidepresivos tricíclicos, que implicó $4,523 millones de pesos (359 millones de dólares). De los costos, más de 99% correspondieron a medicamentos, y menos de 1% a los costos del programa y del entrenamiento. Es evidente que el mayor costo corresponde a las intervenciones en que se agrega el manejo proactivo de caso. La intervención que tuvo la mejor relación costo-efectividad, considerando un solo tratamiento, fue el uso de ISRS. La combinación más costo-efectiva fue la de antidepresivos tricíclicos con psicoterapia breve y manejo proactivo de caso. Conclusiones Es claro que las intervenciones disponibles para el tratamiento de la depresión evitan un número considerable de AVISAs. Éste es casi seis veces mayor cuando se administran ISRS + psicoterapia + manejo proactivo de caso, lo que permite que las intervenciones resulten costo-efectivas a pesar de que el manejo proactivo de caso aumenta considerablemente los costos de atención a estos pacientes. El efecto específico del manejo proactivo de caso es que evita las recaídas y aumenta el tiempo libre de enfermedad, lo que se traduce en mayor beneficio para el paciente, su familia y la sociedad en general.