Development and psychometric evaluation of the Decision Tool Anxiety Disorders, OCD and PTSD (DTAOP): Facilitating the early detection of patients in need of highly specialized care.

BACKGROUND: Early identification of patients with an anxiety disorder, obsessive-compulsive disorder (OCD), or post-traumatic stress disorder (PTSD) in need of highly specialized care could facilitate the selection of the optimal initial treatment in these patients. This paper describes the development and psychometric evaluation of the Decision Tool Anxiety Disorders, OCD and PTSD (DTAOP), which aims to aid clinicians in the early identification of patients with an anxiety disorder, OCD, or PTSD in need of highly specialized mental healthcare. METHODS: A systematic literature review and a concept mapping procedure were carried out to inform the development of the DTAOP. To evaluate the psychometric properties of the DTAOP, a cross-sectional study in 454 patients with a DSM-IV-TR anxiety disorder was carried out. Feasibility was evaluated by the completion time and the content clarity of the DTAOP. Inter-rater reliability was assessed in a subsample of 87 patients. Spearman's rank correlation coefficients between the DTAOP and EuroQol five-dimensional questionnaire (EQ-5D-5L) scores were computed to examine the convergent validity. Criterion validity was assessed against independent clinical judgments made by clinicians. RESULTS: The average time required to complete the eight-item DTAOP was 4.6 min and the total DTAOP was evaluated as clear in the majority (93%) of the evaluations. Krippendorff's alpha estimates ranged from 0.427 to 0.839. Based on the qualitative feedback, item wording and instructions were improved. As hypothesized, the DTAOP correlated negatively with EQ-5D-5L scores. The area under the curve was 0.826 and the cut-off score of ≥4 optimized sensitivity (70%) and specificity (71%). CONCLUSIONS: The DTAOP demonstrated excellent feasibility and good validity, but weak inter-rater reliability. Based on the qualitative feedback and reliability estimates, revisions and refinements of the wording and instructions were made, resulting in the final version of the DTAOP.

Presentation and validation of the Abbreviated Self Completion Teen-Addiction Severity Index (ASC T-ASI): A preference-based measure for use in health-economic evaluations.

Economic evaluations of new youth mental health interventions require preference-based outcome measures that capture the broad benefits these interventions can have for adolescents. The Abbreviated Self Completion Teen-Addiction Severity Index (ASC T-ASI) was developed to meet the need for such a broader measure. It assesses self reported problems in seven important domains of adolescents' lives, including school performance and family relationships, and is intended for use in economic evaluations of relevant interventions. The aim of the current study was to present the ASC T-ASI and examine its validity as well as its ability to distinguish between adolescents with and without problems associated with substance use and delinquency. The validation study was conducted in a sample of adolescents (n = 167) aged 12-18 years, who received in- or outpatient care in a youth mental health and (enclosed) care facility in the Netherlands. To examine its feasibility, test-retest reliability, and convergent validity, respondents completed the ASC T-ASI, as well as the EQ-5D-3L and SDQ at baseline and after a two-week interval using a counterbalanced method. The ASC T-ASI descriptive system comprises seven domains: substance use, school, work, family, social relationships, justice, and mental health, each expressing self reported problems on a five-point Likert scale (ranging from having 'no problem' to having a 'very large problem'). The majority of respondents (>70%) completed the ASC T-ASI within 10 minutes and appraised the questions as (very) easy and (very) comprehensible. Test-retest reliability was adequate (Kw values 0.26-0.55). Correlations with the supplementary measures were moderate to high (rs 0.30-0.50), suggesting convergent validity. The ASC T-ASI is a promising and valid measure for assessing self reported problems in important domains in adolescents' lives, allowing benefits beyond health and health-related quality of life to be included in economic evaluations of youth mental health interventions. Future studies of the ASC T-ASI should consider the comprehensiveness of its domains and sensitivity to change.

Unit Costs of Delinquent Acts for Use in Economic Evaluations.

BACKGROUND: Youth mental health interventions aimed at reducing substance use and delinquency in adolescents compete with other types of interventions for reimbursement from public funding. Within the youth mental health domain, delinquent acts impose high costs on society. These costs should be included in economic evaluations conducted from a societal perspective. Although the relevance of these costs is recognized, they are often left out because the unit costs of delinquent acts are unknown. AIMS OF THE STUDY: This study aims to provide a method for estimating the unit costs per perpetrator of 14 delinquent acts common in the Netherlands and included in self reported delinquency questionnaires: robbery/theft with violence, simple theft/pickpocketing, receiving stolen goods, destruction/vandalism of private or public property, disorderly conduct/discrimination, arson, cybercrime, simple and aggravated assault, threat, forced sexual contact, unauthorised driving, driving under the influence, dealing in soft drugs, and dealing in hard drugs. METHODS: Information on government expenditures and the incidence of crimes, number of perpetrators, and the percentage of solved and reported crimes was obtained from the national database on crime and justice of the Research and Documentation Centre of the Ministry of Justice and Security, Statistics Netherlands, and the Council for the Judiciary in the Netherlands. We applied a top-down micro costing approach to calculate the point estimate of the unit costs for each of the delinquent acts and, subsequently, estimated the mean (SD) unit costs for each of the delinquent acts by taking random draws from a triangular distribution while taking into account a 10% uncertainty associated with the associated point estimate. RESULTS: The mean (SD) unit costs per delinquent act per perpetrator ranged between EUR495 (EUR1.30) for "Driving under the influence" and EUR33,813 (EUR78.30) for a "Cybercrime". These unit costs may be considered as outliers as most unit costs ranged between EUR 2,600 and EUR 13,500 per delinquent act per perpetrator. DISCUSSION: This study is the first to estimate the unit costs per delinquent act per perpetrator in the Netherlands. The results of this study enable the inclusion of government expenditures associated with crime and justice in economic evaluations conducted from a societal perspective. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Youth mental health interventions aimed at reducing substance use and delinquency in adolescents are increasingly subjected to economic evaluations. These evaluations are used to inform decisions concerning the allocation of scarce healthcare resources and should cover all the costs and benefits for society, including those associated with delinquent acts. IMPLICATIONS FOR HEALTH POLICIES: The results of this study facilitate economic evaluations of youth mental health interventions aimed at reducing substance use and delinquency in adolescents, conducted from a societal perspective. IMPLICATIONS FOR FURTHER RESEARCH: Based on health-economic evaluations conducted in the field of youth mental health and the results of the current study, we recommend including the estimated unit costs in guidelines for health-economic evaluations conducted from a societal perspective. Future research could aim at examining whether these unit costs require regular updating. The methodology applied in this study allows for this.

The decision tool unipolar depression (DTUD): a new measure to facilitate the early identification of patients with major depressive disorder in need of highly specialized care.

BACKGROUND: Selection of the optimal initial treatment in patients with major depressive disorder (MDD) in need of highly specialized care has the potential to benefit treatment outcomes and cost-effectiveness of treatment strategies. However, to date, there is a paucity of measures that could guide the selection of the initial treatment, in particular to indicate which patients with MDD are in need of highly specialized care. Recognizing this gap, this paper reports on the development and psychometric evaluation of the Decision Tool Unipolar Depression (DTUD), aimed to facilitate the early identification of patients with MDD in need of highly specialized care. METHODS: The DTUD was developed using a mixed-methods approach, consisting of a systematic review and a concept mapping study. To evaluate the psychometric features of the DTUD, a cross-sectional multicenter study was conducted. A total of 243 patients with MDD were evaluated with the DTUD. Feasibility was operationalized as the time required to complete the DTUD and the content clarity of the DTUD. Inter-rater reliability was evaluated using Krippendorf's alpha. The Maudsley Staging Method (MSM) and the Dutch Measure for quantification of Treatment Resistance in Depression (DM-TRD) were administered to assess the convergent validity. A receiver operator characteristic curve was generated to evaluate the criterion validity and establish the optimal cut-off value. RESULTS: The mean administration time was 4.49 min (SD = 2.71), and the content of the total DTUD was judged as clear in 94.7% of the evaluations. Inter-rater reliability values ranged from 0.69 to 0.91. Higher scores on the DTUD were associated with higher scores on the MSM (rs = 0.47) and DM-TRD (rs = 0.53). Based on the maximum Youden index (0.494), maximum discrimination was reached at a cut-off score of ≥5 (sensitivity 67%, specificity 83%). CONCLUSION: The DTUD demonstrated to be a tool with solid psychometric properties and, therefore, is a promising measure for the early identification of patients with MDD in need of highly specialized care. Use of the DTUD has the potential to facilitate the selection and initiation of the optimal initial treatment in patients with MDD, which in turn may improve the clinical effectiveness and cost-effectiveness of treatment strategies.

Cost-utility of collaborative care for the treatment of comorbid major depressive disorder in outpatients with chronic physical conditions. A randomized controlled trial in the general hospital setting (CC-DIM).

PURPOSE: Major depressive disorder (MDD) is highly prevalent in patients with a chronic physical condition, and this comorbidity has a negative influence on quality of life, health care costs, self-care, morbidity, and mortality. Research has shown that collaborative care (CC) may be a cost-effective treatment. However, its cost-effectiveness in this patient group has not yet been established. Therefore, the aim of this study was to evaluate the cost-utility of CC for the treatment of comorbid MDD in chronically ill patients in the outpatient general hospital setting. The study was conducted from a health care and societal perspective. PATIENTS AND METHODS: In this randomized controlled trial, 81 patients with moderate-to-severe MDD were included; 42 were randomly assigned to the CC group and 39 to the care as usual (CAU) group. We applied the TiC-P, short-form Health-Related Quality of Life questionnaire, and EuroQol EQ-5D 3 level version, measuring the use of health care, informal care, and household work, respectively, at baseline and at 3, 6, 9, and 12 months follow-up. RESULTS: The mean annual direct medical costs in the CC group were €6,718 (95% confidence interval [CI]: 3,541 to 10,680) compared to €4,582 (95% CI: 2,782 to 6,740) in the CAU group. The average quality-adjusted life years (QALYs) gained were 0.07 higher in the CC group, indicating that CC is more costly but also more effective than CAU. From a societal perspective, the incremental cost-effectiveness ratio was €24,690/QALY. CONCLUSION: This first cost-utility analysis in chronically ill patients with comorbid MDD shows that CC may be a cost-effective treatment depending on willingness-to-pay levels. Nevertheless, the low utility scores emphasize the need for further research to improve the cost-effectiveness of CC in this highly prevalent and costly group of patients.

Development and Validation of a Decision Tool for Early Identification of Adult Patients with Severe and Complex Eating Disorder Psychopathology in Need of Highly Specialized Care.

Patients with complex and severe eating disorders often receive a number of ineffective or/and insufficient treatments. Direct referral of these patients to highly specialized tertiary treatment facilities in an earlier stage of the disorder is likely to be more (cost)-effective. The aim of the study was to develop a decision tool that aids clinicians in early identification of these patients. After identification of criteria that were indicative of severity and complexity of eating disorder psychopathology by means of a systematic review of literature and consultation of a focus group, a Delphi method was applied to obtain consensus from experts on the list of relevant criteria. Finally, the decision tool was validated in clinical practice, and cut-off criteria were established. The tool demonstrated good feasibility and validity to identify patients for highly specialized tertiary care. The final decision tool consisted of five criteria that can easily be implemented in clinical practice. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Indicators of patients with major depressive disorder in need of highly specialized care: A systematic review.

OBJECTIVES: Early identification of patients with major depressive disorder (MDD) that cannot be managed by secondary mental health services and who require highly specialized mental healthcare could enhance need-based patient stratification. This, in turn, may reduce the number of treatment steps needed to achieve and sustain an adequate treatment response. The development of a valid tool to identify patients with MDD in need of highly specialized care is hampered by the lack of a comprehensive understanding of indicators that distinguish patients with and without a need for highly specialized MDD care. The aim of this study, therefore, was to systematically review studies on indicators of patients with MDD likely in need of highly specialized care. METHODS: A structured literature search was performed on the PubMed and PsycINFO databases following PRISMA guidelines. Two reviewers independently assessed study eligibility and determined the quality of the identified studies. Three reviewers independently executed data extraction by using a pre-piloted, standardized extraction form. The resulting indicators were grouped by topical similarity, creating a concise summary of the findings. RESULTS: The systematic search of all databases yielded a total of 7,360 references, of which sixteen were eligible for inclusion. The sixteen papers yielded a total of 48 unique indicators. Overall, a more pronounced depression severity, a younger age of onset, a history of prior poor treatment response, psychiatric comorbidity, somatic comorbidity, childhood trauma, psychosocial impairment, older age, and a socioeconomically disadvantaged status were found to be associated with proxies of need for highly specialized MDD care. CONCLUSIONS: Several indicators are associated with the need for highly specialized MDD care. These indicators provide easily measurable factors that may serve as a starting point for the development of a valid tool to identify patients with MDD in need of highly specialized care.

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.

Cost-Effectiveness of Short-Term Inpatient Psychotherapy Based on Transactional Analysis in Patients With Personality Disorder.

Short-term inpatient psychotherapy based on transactional analysis (STIP-TA) in patients with personality disorders (PD) has shown to be more effective than comparable other specialized psychotherapies (OP). The aim of this study was to assess whether the higher effectiveness of STIP-TA also results in a better cost-effectiveness. Patients treated with STIP-TA were matched with patients treated with OP by the propensity score. Healthcare costs and lost productivity costs were measured over 3 years and from the societal perspective. Cost-effectiveness was represented by costs per quality adjusted life years (QALYs). Uncertainty was assessed using bootstrapping. Mean 3-year costs were €59,834 for STIP-TA and €69,337 for OP, a difference of -€9,503, 95% CI [-32,561, 15,726]. QALYs were 2.29 for STIP-TA and 2.05 for OP, a difference of .24, 95% CI [.05, .44]. STIP-TA is a dominant treatment compared to OP: less costly and more effective. We conclude that STIP-TA is a cost-effective treatment in PD patients.

Cost-effectiveness of blended vs. face-to-face cognitive behavioural therapy for severe anxiety disorders: study protocol of a randomized controlled trial.

BACKGROUND: Anxiety disorders are among the most prevalent psychiatric conditions, and are associated with poor quality of life and substantial economic burden. Cognitive behavioural therapy is an effective treatment to reduce anxiety symptoms, but is also costly and labour intensive. Cost-effectiveness could possibly be improved by delivering cognitive behavioural therapy in a blended format, where face-to-face sessions are partially replaced by online sessions. The aim of this trial is to determine the cost-effectiveness of blended cognitive behavioural therapy for adults with anxiety disorders, i.e. panic disorder, social phobia or generalized anxiety disorder, in specialized mental health care settings compared to face-to-face cognitive behavioural therapy. In this paper, we present the study protocol. It is hypothesized that blended cognitive behavioural therapy for anxiety disorders is clinically as effective as face-to-face cognitive behavioural therapy, but that intervention costs may be reduced. We thus hypothesize that blended cognitive behavioural therapy is more cost-effective than face-to-face cognitive behavioural therapy. METHODS/DESIGN: In a randomised controlled equivalence trial 156 patients will be included (n = 78 in blended cognitive behavioural therapy, n = 78 in face-to-face cognitive behavioural therapy) based on a power of 0.80, calculated by using a formula to estimate the power of a cost-effectiveness analysis: [Formula: see text]. Measurements will take place at baseline, midway treatment (7 weeks), immediately after treatment (15 weeks) and 12-month follow-up. At baseline a diagnostic interview will be administered. Primary clinical outcomes are changes in anxiety symptom severity as measured with the Beck Anxiety Inventory. An incremental cost-effectiveness ratio will be calculated to obtain the costs per quality-adjusted life years (QALYs) measured by the EQ-5D (5-level version). Health-economic outcomes will be explored from a societal and health care perspective. DISCUSSION: This trial will be one of the first to provide information on the cost-effectiveness of blended cognitive behavioural therapy for anxiety disorders in routine specialized mental health care settings, both from a societal and a health care perspective. TRIAL REGISTRATION: Netherlands Trial Register NTR4912. Registered 13 November 2014.

Cost-utility of collaborative care for major depressive disorder in primary care in the Netherlands.

OBJECTIVE: Major depression is a great burden on society, as it is associated with high disability/costs. The aim of this study was to evaluate the cost-utility of Collaborative Care (CC) for major depressive disorder compared to Care As Usual (CAU) in a primary health care setting from a societal perspective. METHODS: A cluster randomized controlled trial was conducted, including 93 patients that were identified by screening (45-CC, 48-CAU). Another 57 patients were identified by the GP (56-CC, 1-CAU). The outcome measures were TiC-P, SF-HQL and EQ-5D, respectively measuring health care utilization, production losses and general health related quality of life at baseline three, six, nine and twelve months. A cost-utility analysis was performed for patients included by screening and a sensitivity analysis was done by also including patients identified by the GP. RESULTS: The average annual total costs was €1131 (95% C.I., €-3158 to €750) lower for CC compared to CAU. The average quality of life years (QALYs) gained was 0.02 (95% C.I., -0.004 to 0.04) higher for CC, so CC was dominant from a societal perspective. Taking a health care perspective, CC was less cost-effective due to higher costs, €1173 (95% C.I., €-216 to €2726), of CC compared to CAU which led to an ICER of 53,717 Euro/QALY. The sensitivity analysis showed dominance of CC. CONCLUSION: The cost-utility analysis from a societal perspective showed that CC was dominant to CAU. CC may be a promising treatment for depression in the primary care setting. Further research should explore the cost-effectiveness of long-term CC. TRIAL REGISTRATION: Netherlands Trial Register ISRCTN15266438.

Cost utility analysis of a collaborative stepped care intervention for panic and generalized anxiety disorders in primary care.

OBJECTIVE: Generalized anxiety and panic disorders are a burden on the society because they are costly and have a significant adverse effect on quality of life. The aim of this study was to evaluate the cost-utility of a collaborative stepped care intervention for panic disorder and generalized anxiety disorder in primary care compared to care as usual from a societal perspective. METHODS: The design of the study was a two armed cluster randomized controlled trial. In total 43 primary care practices in the Netherlands participated in the study. Eventually, 180 patients were included (114 collaborative stepped care, 66 care as usual). Baseline measures and follow-up measures (3, 6, 9 and 12 months) were assessed using questionnaires. We applied the TiC-P, the SF-HQL and the EQ-5D respectively measuring health care utilization, production losses and health related quality of life. RESULTS: The average annual direct medical costs in the collaborative stepped care group were 1854 Euro (95% C.I., 1726 to 1986) compared to €1503 (95% C.I., 1374 to 1664) in the care as usual group. The average quality of life years (QALYs) gained was 0.05 higher in the collaborative stepped care group, leading to an incremental cost effectiveness ratio (ICER) of 6965 Euro per QALY. Inclusion of the productivity costs, consequently reflecting the full societal costs, decreased the ratio even more. CONCLUSION: The study showed that collaborative stepped care was a cost effective intervention for panic disorder and generalized anxiety disorder and was even dominant when a societal perspective was taken. TRIAL REGISTRATION: trialregister.nl, Netherlands Trial Register NTR107.

Cost-utility analysis of a collaborative care intervention for major depressive disorder in an occupational healthcare setting.

PURPOSE: Major depression is associated with high levels of absence and reduced productivity. Therefore the costs to society are high. The aim of this study was to evaluate the cost-utility of collaborative care for major depressive disorder (MDD) compared to care as usual in an occupational healthcare setting. A societal perspective was taken. METHODS: In this randomised controlled trial, 126 sick-listed workers with MDD were included (65 collaborative care, 61 care as usual). Baseline measurements and follow up measures (3, 6, 9 and 12 months) were assessed by questionnaire. We applied the Trimbos/iMTA questionnaire for costs associated with psychiatric illness, the SF-HQL and the EQ-5D respectively measuring the health care utilization, production losses and general health related quality of life. RESULTS: The average annual healthcare costs in the collaborative care group were €3,874 (95 % CI €2,778-€ 5,718) compared to €4,583 (95 % CI €3,108-€6,794) in the care as usual group. The average quality of life years (QALY's) gained were lower in the collaborative care group, 0.05 QALY. The majority of the ICERS (69 %) indicate that collaborative care is less costly but also less effective than care as usual. Including the productivity costs did not change this result. CONCLUSIONS: The cost-utility analysis showed that collaborative care generated reduced costs and a reduction in effects compared to care as usual and was therefore not a cost-effective intervention.

Novice drivers' performance after different alcohol dosages and placebo in the divided-attention steering simulator (DASS).

RATIONALE: The divided-attention steering simulator (DASS) is designed to measure lane-keeping (i.e., a tracking task using a steering wheel) while performing a secondary visual task (responding to digits that appear in the corners of the computer screen). Some studies have already used the DASS, but the magnitude of impairment is difficult to interpret because reference values are lacking. OBJECTIVE: To examine the magnitude of impairment after administration of four different dosages of alcohol and placebo. MATERIALS AND METHODS: Thirty-two healthy young adults participated in this randomized, single-blind crossover trial. Subjects received alcohol to gain a blood alcohol concentration (BAC) of 0.02%, 0.05%, 0.08%, and 0.10% or alcohol-placebo. Sixteen subjects performed a 30-min test in DASS (dual-task condition). Outcome measures were steering error, reaction time, and percentage of errors. Sixteen other subjects performed the test without performing the secondary peripheral task (single-task condition). RESULTS: Twenty-eight subjects (novice drivers; drivers' license up to 5 years) were included in the analyses. Dose-dependent impairment was found in both the single-task condition (F ((4,11)) = 10.86, p < 0.001) and the dual-task condition (F ((4,9)) = 5.58, p < 0.015). Performance at all BAC levels differed significantly (p < 0.05) from alcohol-placebo, except BAC 0.02%. With increasing BAC levels, subjects made more errors and reacted slower on the peripheral visual search task, but these effects did not reach significance. CONCLUSION: With increasing BAC, dose-dependent impairment was found. The DASS seems to be a suitable divided-attention task that is useful in psychopharmacological research and training of novice drivers.