Cost-effectiveness of cognitive behavioral therapy for insomnia comorbid with depression: Analysis of a randomized controlled trial.

AIM: Although the efficacy of cognitive behavioral therapy for insomnia has been confirmed, dissemination depends on the balance of benefits and costs. This study aimed to examine the cost-effectiveness of cognitive behavioral therapy for insomnia consisting of four weekly individual sessions. METHODS: We conducted a 4-week randomized controlled trial with a 4-week follow up in outpatient clinics in Japan. Thirty-seven patients diagnosed as having major depressive disorder according to DSM-IV and suffering from chronic insomnia were randomized to receive either treatment as usual (TAU) alone or TAU plus cognitive behavioral therapy for insomnia. Effectiveness was evaluated as quality-adjusted life years (QALY) over 8 weeks' time, estimated by bootstrapping of the observed total scores of the Hamilton Depression Rating Scale. Direct medical costs for cognitive behavioral therapy for insomnia and TAU were also evaluated. We calculated the incremental cost-effectiveness ratio. RESULTS: Over the 8 weeks of the study, the group receiving cognitive behavioral therapy for insomnia plus TAU had significantly higher QALY (P = 0.002) than the TAU-alone group with an incremental value of 0.019 (SD 0.006), and had non-significantly higher costs with an incremental value of 254 (SD 203) USD in direct costs. The incremental cost-effectiveness ratio was 13 678 USD (95% confidence interval: -5691 to 71 316). Adding cognitive behavioral therapy for insomnia demonstrated an approximately 95% chance of gaining one more QALY if a decision-maker was willing to pay 60 000 USD, and approximately 90% for 40 000 USD. CONCLUSION: Adding cognitive behavioral therapy for insomnia is highly likely to be cost-effective for patients with residual insomnia and concomitant depression.

Cost-effectiveness of family psychoeducation to prevent relapse in major depression: results from a randomized controlled trial.

BACKGROUND: Family psychoeducation is a relatively simple and straightforward intervention whose prophylactic effectiveness and cost-effectiveness is well-established for schizophrenia. We have recently demonstrated its effectiveness for unipolar depression, but its cost-effectiveness has never been examined. We hereby report a cost-effectiveness analysis alongside a randomized controlled trial in order to assess its cost-effectiveness for preventing relapse/recurrence in depression. METHODS: Fifty-seven patients diagnosed with major depression and undergoing its maintenance treatment, and their primary family members were randomized to treatment as usual (TAU) only or to TAU plus family psychoeducation, which consisted of four 2-hour multiple-family sessions consisting of didactic lectures about depression (30 minutes) and group discussion and problem solving (60-90 minutes). The economic analyses were undertaken from the perspective of the National Health Insurance (NHI), assuming the most reasonable price of US$50 per psychoeducation session per patient. The main outcome measures included relapse-free days and direct costs to the NHI. RESULTS: The intervention group enjoyed 272 (SD: 7.1) relapse-free days, while the control group spent 214 (SD: 90.8) relapse-free days (Cox proportional hazard ratio=0.17, 95%CI: 0.04 to 0.75, p=0.002). Cost-effectiveness acceptability curves suggested that the family psychoeducation has 90% or more chances of being cost-effective if the decision-maker is prepared to pay US$20 for one additional relapse-free day. This cost-effectiveness finding was robust when the price for family psychoeducation ranged between 50% to 150% of the baseline scenario in sensitivity analyses. If a relapse-free day is considered to be worth $30 or more, all the pricing scenarios have a close to 100% probability of being cost-effective. CONCLUSION: Family psychoeducation is effective in the relapse prevention of depression and is highly likely to be cost-effective if a relapse-free day is valued as US$20 or more. TRIAL REGISTRATION: UMIN-CTR (UMIN000005555).

Residential program for long-term hospitalized persons with mental illness in Japan: Randomized controlled trial.

Research on the merits of long-term group residences is inconclusive. The purpose of the present paper was to investigate the effects of supported group residence on the symptoms, social function, quality of life, general health quality, and the medical/psychiatric cost in Japan of a large number of psychiatric beds and long average length of stay. Patients were assessed every 6 months for 2 years using Positive and Negative Syndrome Scale, Katz Adjustment Scale, World Health Organization Quality of Life (WHO-QOL) and General Health Questionnaire 12-item version. Patients discharged to the supported group residence (SGR) significantly improved with regard to positive symptoms, the level of socially expected activities and free-time activities. The QOL physical domain of the inpatients was significantly more deteriorated compared to the SGR group. The total psychiatric/medical cost of the SGR group was approximately one-third that of the inpatient group, while the cost of the SGR to treat physical comorbidity was much higher. The present findings indicate that SGR has advantages for mental and social function but not for physical health. A major limitation of the present study was the high mean age (>60 years) of the subjects who had been hospitalized for a long period (mean, 24 years).

Medical cost analysis of family psychoeducation for schizophrenia.

Family psychoeducation has been shown to prevent the relapse of schizophrenia. However, whether medical costs are reduced by this approach remains uncertain. The subjects were patients with schizophrenia who lived with high-expressed emotion (EE) families and were at high risk of relapse. A total of 30 patients whose families underwent psychoeducation and intensive family sessions or psychoeducation and subsequent support were regarded as the psychoeducation group. A high-EE group without family psychoeducation made up of 24 patients was used as a control group. The mean outpatient medical cost, duration of hospitalization, inpatient medical cost, and total medical cost during the follow-up period were compared between the psychoeducation group and the control group. The mean inpatient medical cost was 270,000 yen in the psychoeducation group and 470,000 yen in the control group. The mean total medical costs were 500,000 yen in the psychoeducation group and 710,000 yen in the control group. The cost in the psychoeducation group was significantly lower than the control group by Mann-Whitney U-test. The proportion of patients with a total medical cost greater than the median value was 23% in the psychoeducation group and 54% in the control group with a significant difference. The medical cost can be reduced in the psychoeducation group compared with the control group due to the prevention of re-hospitalization by family psychoeducation.

A cross-cultural study on expressed emotion in carers of people with dementia and schizophrenia: Japan and England.

Expressed emotion (EE) research has been productive in investigating the influence of the interpersonal environment on a range of disorders. The majority of EE research on the influence of carers has been carried out in the west. This is the first EE study of the carers of people with dementia in Japan. The aim of this study was to investigate the relationships between EE status and aspect of burden through cross-cultural comparison of the two countries, Japan and England, with large cultural and linguistic differences. Comparisons were made between samples of EE of carers of dementia and schizophrenic patients. In total, data on 80 carer/relative-patient dyads were collected and examined: (1) 20 Japanese carers of people with dementia (JD), (2) 20 English carers of patients with Alzheimer's disease (ED), (3) 20 Japanese relatives of patients with schizophrenia (JS), and (4) 20 English relatives of patients with schizophrenia (ES). The Camberwell Family Interview was administered in each country to ascertain levels of EE. Large differences between Japan and England were found in the frequency of critical comments, in which ES>ED>JS>JD. EE correlated significantly with burden in the JD sample alone. With an operational cut-off of 2CC (CC, critical comments), EE correlated significantly with cognitive impairment as well as with clinical severity in the JD sample. There was a tendency for lower expression of both positive and negative emotional reactions towards family members in the Japanese sample. The results of this study indicate that EE is an appropriate measure for use with carers of sufferers of dementia and can be utilized across different cultures. However, flexibility with the cut-offs may be required in Eastern cultures. This needs to be tested on larger samples with sensitivity to illness and cross-cultural differences.