Evaluation of a new model for assessment and treatment of uncomplicated ADHD - effect, patient satisfaction and costs.

Aim: Attention-deficit/hyperactivity disorder (ADHD) is the most common diagnosis within child- and adolescent psychiatry. Waiting lists and delayed care are major issues. The aim was to evaluate if standardized care (SC) for assessment and treatment of uncomplicated ADHD would reduce resource utilization and increase satisfaction with preserved improvement within the first year of treatment.Method: Patients 6-12 years with positive screen for uncomplicated ADHD at the brief child and family phone interview (BCFPI), a routine clinical procedure, were triaged to SC. The control group consisted of patients diagnosed with ADHD in 2014 and treated as usual. BCFPI factors at baseline and follow-up after one year and resource utilization were compared.Results: Patients improved in ADHD symptoms (Cohen's d = 0.78, p < 0.001), child function (Cohen's d = 0.80, p < 0.001) and in family situation (Cohen's d = 0.61, p < 0.001) without group differences. Parents of SC patients participated more often in psychoeducational groups (75.5 vs. 49.5%, p < 0.001). SC had shorter time to ADHD diagnosis (8.4 vs. 15.6 weeks, p = 0.01) and to medication (24.6 vs. 32.1 weeks, p = 0.003). SC families were more satisfied with the waiting time (p = 0.01), otherwise there were no differences in satisfaction between the groups. Families of SC patients had fewer visits (4.7 vs. 10.8, p < 0.001) but used the same number of phone calls (6.3 vs. 6.2, p = 0.71). Costs were 55% lower.Conclusions: A SC for ADHD can markedly reduce costs with preserved quality. As resources are limited, child psychiatry would benefit from standardization.

Cost-effectiveness of Family Group Conferencing in child welfare: a controlled study.

BACKGROUND: This study aimed to examine the short- and long term (cost-) effectiveness of Family Group Conferencing (FGC) compared to care as usual (CAU) in terms of improved child safety, empowerment and social support. METHODS: A subgroup of a larger randomized controlled trial, comprising 69 families in child welfare (experimental group: n = 46; control group: n = 23), was included. RESULTS: No additional effects of FGC on child safety, social support and only short-term positive effects on empowerment were found. There were no differences in costs between FGC and CAU. The chance for FGC to be cost-effective was small. For families who refused FGC, the FGC approach was more cost-effective than CAU, whereas it was less cost-effective for families that prepared or completed FGC. CONCLUSIONS: Overall, FGC is not (cost-)effective in improving child safety, empowerment and social support, but cost-effectiveness varies at different levels of FGC-completion. TRIAL REGISTRATION: Dutch Trial Register number NTR4320 . Registered 17 December 2013.

Scaling-Up Evidence-Based Programs Using a Public Funding Stream: a Randomized Trial of Functional Family Therapy for Court-Involved Youth.

The Affordable Care Act expanded access to Medicaid programs and required them to provide essential health benefits, which can include prevention services. This study assesses the costs and benefits to using Medicaid funding to implement a well-known evidence-based program, Functional Family Therapy (FFT), with a sample of juvenile justice-involved youth. The study also provides a rigorous test of FFT accommodated for a contemporary urban population that is gang at risk or gang-involved. One hundred twenty-nine predominantly minority and low income families were randomly assigned to receive an enhanced version of FFT or an alternative family therapy. Data from pre- and post-intervention interviews with youth and parents, court records of contacts with the justice system and residential placements, official records of community services, and the costs of placements and services are summarized. The intervention was implemented with fidelity to the FFT model using Medicaid funding. Treatment and control subjects received a wide range of community and residential services in addition to FFT. A higher percentage of treatment subjects than controls received services following random assignment, but the cost per youth served was lower for treatment than control youth, primarily because control youth were more often placed in residential facilities. Recidivism during the 18-month follow-up period was lower for FFT than for control youth. The combination of cost savings realized from avoiding more costly services and the expected future savings due to recidivism reduction suggest the expanded use of evidence-based practices using public funding streams such as Medicaid is warranted.

Economic Impact of Multisystemic Therapy for Child Abuse and Neglect.

This study evaluated the economics of Multisystemic Therapy for Child Abuse and Neglect (MST-CAN) by applying the Washington State Institute for Public Policy (WSIPP) cost-benefit model to data from a randomized effectiveness trial with 86 families (Swenson et al. in JFP 24:497-507, 2010b). The net benefit of MST-CAN, versus enhanced outpatient treatment, was $26,655 per family at 16 months post-baseline. Stated differently, every dollar spent on MST-CAN recovered $3.31 in savings to participants, taxpayers, and society at large. Policymakers and public service agencies should consider these findings when making investments into interventions for high-need families involved with child protective services.

The search for relevant outcome measures for cost-utility analysis of systemic family interventions in adolescents with substance use disorder and delinquent behavior: a systematic literature review.

PURPOSE: Systemic family interventions have shown to be effective in adolescents with substance use disorder and delinquent behavior. The interventions target interactions between the adolescent and involved systems (i.e. youth, family, peers, neighbors, school, work, and society). Next to effectiveness considerations, economic aspects have gained attention. However, conventional generic quality of life measures used in health economic evaluations may not be able to capture the broad effects of systemic interventions. This study aims to identify existing outcome measures, which capture the broad effects of systemic family interventions, and allow use in a health economic framework. METHODS: We based our systematic review on clinical studies in the field. Our goal was to identify effectiveness studies of psychosocial interventions for adolescents with substance use disorder and delinquent behavior and to distill the instruments used in these studies to measure effects. Searched databases were PubMed, Education Resource Information Center (ERIC), Cochrane and Psychnet (PsycBOOKSc, PsycCRITIQUES, print). Identified instruments were ranked according to the number of systems covered (comprehensiveness). In addition, their use for health economic analyses was evaluated according to suitability characteristics such as brevity, accessibility, psychometric properties, etc. RESULTS: One thousand three hundred seventy-eight articles were found and screened for eligibility. Eighty articles were selected, 8 instruments were identified covering 5 or more systems. CONCLUSIONS: The systematic review identified instruments from the clinical field suitable to evaluate systemic family interventions in a health economic framework. None of them had preference-weights available. Hence, a next step could be to attach preference-weights to one of the identified instruments to allow health economic evaluations of systemic family interventions.

Statewide Implementation of Parenting with Love and Limits Among Youth with Co-Existing Internalizing and Externalizing Functional Impairments Reduces Return to Service Rates and Treatment Costs.

Many community mental health (CMH) systems contain inefficiencies, contributing to unmet need for services among youth. Using a quasi-experimental research design, we examined the implementation of an adapted structural-strategic family intervention, Parenting with Love and Limits, in a state CMH system to increase efficiency of services to youth with co-existing internalizing and externalizing functional impairments (PLL n = 296; Treatment-As-Usual n = 296; 54% male; 81% Caucasian). Youth receiving PLL experienced shorter treatment durations and returned to CMH services at significantly lower rates than youth receiving treatment-as-usual. They also demonstrated significant decreases in internalizing and externalizing symptoms over time. Findings lay the foundation for further examination of the role of an adapted structural-strategic family treatment in increasing the efficiency of CMH systems.

Making the Business Case for Coverage of Family-Based Behavioral Group Interventions for Pediatric Obesity.

BACKGROUND: Pediatric obesity presents a significant burden. However, family-based behavioral group (FBBG) obesity interventions are largely uncovered by our health care system. The present study uses Return on Investment (ROI) and Internal Rate of Return (IRR) analyses to analyze the business side of FBBG interventions. METHODS: ROI and IRR were calculated to determine longitudinal cost-effectiveness of a FBBG intervention. Multiple simulations of cost savings are projected using three estimated trajectories of weight change and variations in assumptions. RESULTS: The baseline model of child savings gives an average IRR of 0.2% ± 0.08% and an average ROI of 20.8% ± 0.4%, which represents a break-even IRR and a positive ROI. More pessimistic simulations result in negative IRR values. CONCLUSIONS: Under certain assumptions, FBBGs offer a break-even proposition. Results are limited by lack of data regarding several assumptions, and future research should evaluate changes in cost savings following changes in child and adult weight.

The cost-effectiveness of family/family-based therapy for treatment of externalizing disorders, substance use disorders and delinquency: a systematic review.

BACKGROUND: Family therapy and family-based treatment has been commonly applied in children and adolescents in mental health care and has been proven to be effective. There is an increased interest in economic evaluations of these, often expensive, interventions. The aim of this systematic review is to summarize and evaluate the evidence on cost-effectiveness of family/family-based therapy for externalizing disorders, substance use disorders and delinquency. METHODS: A systematic literature search was performed in PubMed, Education Resource information Centre (ERIC), Psycinfo and Cochrane reviews including studies conducted after 1990 and before the first of August of 2013. Full economic evaluations investigating family/family-based interventions for adolescents between 10 and 20 years treated for substance use disorders, delinquency or externalizing disorders were included. RESULTS: Seven hundred thirty-one articles met the search criteria and 51 studies were initially selected. The final selection resulted in the inclusion of 11 studies. The quality of these studies was assessed. Within the identified studies, there was great variation in the specific type of family/family-based interventions and disorders. According to the outcomes of the checklists, the overall quality of the economic evaluations was low. Results varied by study. Due to the variations in setting, design and outcome it was not feasible to pool results using a meta-analysis. CONCLUSIONS: The quality of the identified economic evaluations of family/family-based therapy for treatment of externalizing disorders, adolescent substance use disorders and delinquency was insufficient to determine the cost-effectiveness. Although commonly applied, family/family-based therapy is costly and more research of higher quality is needed.

Short-term intensive family therapy for adolescent eating disorders: 30-month outcome.

Family therapy approaches have generated impressive empirical evidence in the treatment of adolescent eating disorders (EDs). However, the paucity of specialist treatment providers limits treatment uptake; therefore, our group developed the intensive family therapy (IFT)-a 5-day treatment based on the principles of family-based therapy for EDs. We retrospectively examined the long-term efficacy of IFT in both single-family (S-IFT) and multi-family (M-IFT) settings evaluating 74 eating disordered adolescents who underwent IFT at the University of California, San Diego, between 2006 and 2013. Full remission was defined as normal weight (≥ 95% of expected for sex, age, and height), Eating Disorder Examination Questionnaire (EDE-Q) global score within 1 SD of norms, and absence of binge-purging behaviours. Partial remission was defined as weight ≥ 85% of expected or ≥ 95% but with elevated EDE-Q global score and presence of binge-purging symptoms (<1/week). Over a mean follow-up period of 30 months, 87.8% of participants achieved either full (60.8%) or partial remission (27%), while 12.2% reported a poor outcome, with both S-IFT and M-IFT showing comparable outcomes. Short-term, intensive treatments may be cost-effective and clinically useful where access to regular specialist treatment is limited.

Italian families and family interventions.

In Italy, as in many countries, relatives are closely involved in caring for persons with physical and mental disorders. The Italian scenario lends itself to routine involvement of family members in psychiatric treatment because, despite becoming smaller and smaller, Italian families keep close ties, and men and women do not leave the parental home until relatively late. The authors describe the impact of international family psychosocial research on the Italian mental health services (MHSs) and the main psychosocial interventions currently in use, including family psychoeducational interventions and the "Milan family therapy approach." They also highlight the contribution Italian researchers have given to the study of important variables in integrated mental disorder care, such as family burden of care, relatives' attitudes, family functioning, and satisfaction with the MHSs. Finally, they discuss the difficulties of implementing and disseminating family interventions within the Italian MHS, despite the growing evidence of their effectiveness.

The effectiveness and cost-effectiveness of attachment-based family therapy for young adults with high suicidal ideation: protocol of a randomized controlled trial.

BACKGROUND: Young adult suicidality is worldwide a prevalent mental health problem and the number one cause of death, with devastating consequences for individuals and their families, and substantial economic costs. However, psychological and pharmacological treatments currently recommended in guidelines for treatment of high-risk youth for fatal suicide have limited effect. In line with the World Health Organization's (WHO) recommendation to involve the family in treatment of these youth, attachment-based family therapy (ABFT) was developed, a 16-week attachment and emotion-focused treatment, implemented in mental health care settings across various European countries in the past years, and becoming increasingly popular among therapists. However, the (cost-)effectiveness of ABFT has not been studied in emerging adults. In the proposed pragmatic randomized controlled trial (RCT), we aim to evaluate the effectiveness and cost-effectiveness of ABFT compared to treatment as usual (TAU) on suicidality, as delivered in daily practice. METHODS: This pragmatic multicenter study in the Netherlands and Belgium includes 13 participating sites. Participants are suicidal young adults (≥ 31 SIQ-JR score) between 16 and 30 years old who seek mental health treatment (n = 142) and their caregivers. The primary outcome is suicidality (SIQ-JR), with assessments at baseline, post-intervention (5 months after baseline), 3, 6, and 12 months after intervention. We predict that, compared to TAU, ABFT will lead to a stronger reduction in suicidality and will be more cost-effective, over the course of all time points. We also expect stronger decreases in depressive symptoms, given that suicidality is very common in individuals with depressive disorder, as well as more improvement in family functioning, autonomy, entrapment, and young adult attachment, in the ABFT condition. DISCUSSION: This study can contribute to improving the care for suicidal youngsters with high mortality risk. Treatment of suicidal emerging adults is understudied. The results will inform clinical guidelines and policy makers and improve treatment of suicidal emerging adults. TRIAL REGISTRATION: This trial is registered on ClinicalTrials.gov (NCT05965622, first posted on July 28, 2023).

Cost-effectiveness of early intervention in first-episode psychosis: economic evaluation of a randomised controlled trial (the OPUS study).

BACKGROUND: Information about the cost-effectiveness of early intervention programmes for first-episode psychosis is limited. AIMS: To evaluate the cost-effectiveness of an intensive early-intervention programme (called OPUS) (trial registration NCT00157313) consisting of enriched assertive community treatment, psychoeducational family treatment and social skills training for individuals with first-episode psychosis compared with standard treatment. METHOD: An incremental cost-effectiveness analysis of a randomised controlled trial, adopting a public sector perspective was undertaken. RESULTS: The mean total costs of OPUS over 5 years (€123,683, s.e. = 8970) were not significantly different from that of standard treatment (€148,751, s.e. = 13073). At 2-year follow-up the mean Global Assessment of Functioning (GAF) score in the OPUS group (55.16, s.d. = 15.15) was significantly higher than in standard treatment group (51.13, s.d. = 15.92). However, the mean GAF did not differ significantly between the groups at 5-year follow-up (55.35 (s.d. = 18.28) and 54.16 (s.d. = 18.41), respectively). Cost-effectiveness planes based on non-parametric bootstrapping showed that OPUS was less costly and more effective in 70% of the replications. For a willingness-to-pay up to €50,000 the probability that OPUS was cost-effective was more than 80%. CONCLUSIONS: The incremental cost-effectiveness analysis showed that there was a high probability of OPUS being cost-effective compared with standard treatment.

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).

Framework for modelling the cost-effectiveness of systemic interventions aimed to reduce youth delinquency.

BACKGROUND: Many interventions initiated within and financed from the health care sector are not necessarily primarily aimed at improving health. This poses important questions regarding the operationalisation of economic evaluations in such contexts. AIMS OF THE STUDY: We investigated whether assessing cost-effectiveness using state-of-the-art methods commonly applied in health care evaluations is feasible and meaningful when evaluating interventions aimed at reducing youth delinquency. METHODS: A probabilistic Markov model was constructed to create a framework for the assessment of the cost-effectiveness of systemic interventions in delinquent youth. For illustrative purposes, Functional Family Therapy (FFT), a systemic intervention aimed at improving family functioning and, primarily, reducing delinquent activity in youths, was compared to Treatment as Usual (TAU). "Criminal activity free years" (CAFYs) were introduced as central outcome measure. Criminal activity may e.g. be based on police contacts or committed crimes. In absence of extensive data and for illustrative purposes the current study based criminal activity on available literature on recidivism. Furthermore, a literature search was performed to deduce the model's structure and parameters. RESULTS: Common cost-effectiveness methodology could be applied to interventions for youth delinquency. Model characteristics and parameters were derived from literature and ongoing trial data. The model resulted in an estimate of incremental costs/CAFY and included long-term effects. Illustrative model results point towards dominance of FFT compared to TAU. DISCUSSION: Using a probabilistic model and the CAFY outcome measure to assess cost-effectiveness of systemic interventions aimed to reduce delinquency is feasible. However, the model structure is limited to three states and the CAFY measure was defined rather crude. Moreover, as the model parameters are retrieved from literature the model results are illustrative in the absence of empirical data. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The current model provides a framework to assess the cost-effectiveness of systemic interventions, while taking into account parameter uncertainty and long-term effectiveness. IMPLICATIONS FOR HEALTH POLICIES: The framework of the model could be used to assess the cost-effectiveness of systemic interventions alongside (clinical) trial data. Consequently, it is suitable to inform reimbursement decisions, since the value for money of systemic interventions can be demonstrated using a decision analytic model. IMPLICATIONS FOR FURTHER RESEARCH: Future research could be focussed on testing the current model based on extensive empirical data, improving the outcome measure and finding appropriate values for that outcome.

Interventions provided by parents for children with intellectual disabilities in low and middle income countries.

BACKGROUND: In low- and middle-income (LAMI) countries, there is a lack of well-trained therapists to provide specialist interventions for children with intellectual disabilities and their families. We sought to identify strategies deliverable by families or non-specialist workers. MATERIALS AND METHODS: After searches of appropriate scientific databases, we applied GRADE methodology to rate the quality of evidence for these interventions. RESULTS: We identified small-scale interventions trialled in LAMI countries with limited evidence of effectiveness in supporting development, adaptive behaviour and/or community participation. In high-income countries, the Stepping Stones Triple P program for adaptive behaviour and the Portage program for child development have the most extensive evidence base and may be applicable in LAMI countries. CONCLUSIONS: There is reason to hope that, when combined with community development strategies, the welfare of children with intellectual disabilities in LAMI countries can be advanced within those countries' economic means.

Which psychosocial interventions in bipolar depression?

This review of psychosocial interventions in bipolar disorders demonstrates that some therapies, when combined with medication, are more efficacious at preventing or delaying depressive relapse, and can be more effective than medication alone in reducing time to recovery from an acute bipolar depressive episode. However, apparent benefits diminish over time, suggesting that maintenance or « booster ¼ therapy sessions may be needed. Given the scarcity of trained therapists, further studies are needed to determine which bipolar depressed patients should be targeted and to establish more clearly the potential cost and benefits of such interventions.

[Multisystemic Therapy (MST) for youths with severe conduct disorders - economic evaluation of the implementation in a German-speaking environment]. / Multisystemische Therapie (MST) für Jugendliche mit schweren Störungen des Sozialverhaltens.

OBJECTIVE: Multisystemic Therapy (MST) was adapted for implementation in a German-speaking environment. The study evaluates the possible economic effects of MST. METHOD: Professionals who recommended MST for youths with severe conduct disorders were asked to evaluate the probability of other forms of interventions if MST had not been used. We investigated the costs of those other forms of treatment and compared them to the costs that had actually been incurred with MST. RESULTS: Implementation of MST in a German-speaking environment showed a significant potential of cost savings compared to other intervention methods. The costs of MST per case were between 40 % and 64 % lower than these of standard interventions. CONCLUSIONS: MST is not only an effective, but also a cost-efficient form of evidence-based treatment for youths with severe conduct disorders.

Comparative Costs of a Parent-Only and Parent and Child Treatment for Children with Overweight or Obesity.

OBJECTIVE: Models such as family-based treatment (FBT), delivered to both the parent and child, are considered the most efficacious intervention for children with obesity. However, recent research suggests that parent-based treatment (PBT; or parent-only treatment) is noninferior to FBT. The aim of this study was to evaluate the comparative costs of the FBT and PBT models. METHODS: A total of 150 children with overweight and obesity and their parents were randomized to one of two 6-month treatment programs (FBT or PBT). Data was collected at baseline, during treatment, and following treatment, and and trial-based analyses of the costs were conducted from a health care sector perspective and a limited societal perspective. RESULTS: Results suggest that PBT, compared with FBT, had lower costs per parent-child dyad from the health care sector perspective (PBT = $2,886; FBT = $3,899) and from a limited societal perspective (PBT = $3,231; FBT = $4,279). CONCLUSIONS: These findings suggest that a PBT intervention has lower costs and is noninferior to an FBT intervention for both child and parent weight loss.

Strengthening Clinical Research in Marriage and Family Therapy: Challenges and Multilevel Solutions.

There is a critical need for high-quality and accessible treatments to improve mental health. Yet, there are indications that the research being conducted by contemporary marriage and family therapy (MFT) scholars focuses less on advancing and disseminating clinical interventions than in previous decades. In this article, we describe challenges to increasing rigorous clinical research in MFT. We use systems mapping and the intervention-level framework to identify strategic goals designed to drive innovation in clinical research in the field. It is our hope this article encourages dialog and action among MFT stakeholder groups to support clinical science that will improve the health and functioning of families.