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1.
Expert Rev Pharmacoecon Outcomes Res ; 19(6): 663-676, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31859542

RESUMO

Introduction: Health anxiety, also known as 'hypochondriasis', is a common, distressing and costly condition that responds to cognitive behavior therapy (CBT) but evidence pertaining to response and remission rates, treatment in routine care, therapist-guided Internet-delivered CBT (ICBT) and health economics has not been systematically reviewed.Areas covered: In this systematic review and meta-analysis we searched PubMed, PsycINFO, and OATD (17/06/2019) for randomized controlled trials (RCTs) comparing CBT to non-CBT controls for health anxiety. Based on 19 RCTs, the pooled between-group effect on health anxiety was moderate to large (g = 0.79; 95% CI: 0.57-1.01; adjusted for publication bias: g = 0.62), with small to moderate effects on secondary symptoms and effects largely sustained 12-18 months after treatment. Moderators were control condition and recruitment path, but not treatment setting. The pooled CBT response rate was 66%, and the remission rate 48%. ICBT had effects comparable to face-to-face CBT. CBT for health anxiety is probably cost-effective, but with limited effect on the quality of life.Expert opinion: CBT is a highly efficacious and probably cost-effective treatment for health anxiety. We recommend that ICBT is implemented more widely, and that health economic outcomes and ways of increasing response and remission rates are explored further.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Hipocondríase/terapia , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício , Economia Médica , Humanos , Hipocondríase/economia , Internet , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
2.
Medicine (Baltimore) ; 98(41): e17289, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593081

RESUMO

INTRODUCTION: Fibromyalgia (FM) is a chronic condition characterized by chronic pain, fatigue and loss of function which significantly impairs quality of life. Although treatment of FM remains disputed, some studies point at the efficacy of interdisciplinary therapy. This study aims to analyze the effectiveness, cost-utility and benefits of a multicomponent therapy on quality of life (main variable), functional impact, mood and pain in people suffering from FM that attend primary care centers (PCCs) of the Catalan Institute of Health (ICS). METHODS AND ANALYSIS: A 2-phase, mixed methods study has been designed following Medical Research Council guidance. Phase 1: Pragmatic randomized clinical trial with patients diagnosed with FM that attend one of the 11 PCCs of the ICS Gerència Territorial Terres de l'Ebre. We estimate a total sample of 336 patients. The control group will receive usual clinical care, while the multicomponent therapy group (MT group) will receive usual clinical care plus group therapy (consisting of health education, exercise and cognitive-behavioural therapy) during 12 weeks in 2-hourly weekly sessions. ANALYSIS: the standardized mean response and the standardized effect size will be assessed at 3, 9, and 15 months after the beginning of the study using multiple linear regression models. Utility measurements will be used for the economic analysis. Phase 2: Qualitative socio constructivist study to evaluate the intervention according to the results obtained and the opinions and experiences of participants (patients and professionals). We will use theoretical sampling, with 2 discussion groups of participants in the multicomponent therapy and 2 discussion groups of professionals of different PCCs. A thematic content analysis will be carried out. ETHICS AND DISSEMINATION: This study protocol has been approved by the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P18/068). Articles will be published in international, peer-reviewed scientific journals. TRIAL REGISTRATION: Clinical-Trials.gov: NCT04049006.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Terapia por Exercício/métodos , Fibromialgia/terapia , Educação de Pacientes como Assunto/métodos , Atenção Primária à Saúde/métodos , Qualidade de Vida , Adulto , Terapia Cognitivo-Comportamental/economia , Terapia Combinada , Análise Custo-Benefício , Terapia por Exercício/economia , Estudos de Viabilidade , Feminino , Fibromialgia/economia , Fibromialgia/psicologia , Implementação de Plano de Saúde , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde , Cooperação do Paciente , Educação de Pacientes como Assunto/economia , Atenção Primária à Saúde/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa
3.
Health Psychol ; 38(8): 680-688, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31368752

RESUMO

In this report, we offer three examples of how economic data could promote greater adoption of behavioral and psychosocial interventions in clinical settings where primary or specialty medical care is delivered to patients. The examples are collaborative care for depression, chronic pain management, and cognitive-behavioral therapy for insomnia. These interventions illustrate differences in the availability of cost and cost-effectiveness data and in the extent of intervention adoption and integration into routine delivery of medical care. Collaborative care has been widely studied from an economic perspective, with most studies demonstrating its relative cost-effectiveness per quality-adjusted life year (QALY) and some studies demonstrating its potential for cost neutrality or cost savings. The success of collaborative care for depression can be viewed as a model for how to promote greater adoption of other interventions, such as psychological therapies for chronic pain and insomnia. (PsycINFO Database Record (c) 2019 APA, all rights reserved).


Assuntos
Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício/métodos , Humanos
4.
BMC Public Health ; 19(1): 905, 2019 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-31286908

RESUMO

BACKGROUND: Delay to start antiretroviral therapy (ART) and nonadherence compromise the health and wellbeing of people living with HIV (PLWH), raise the cost of care and increase risk of transmission to sexual partners. To date, interventions to improve adherence to ART have had limited success, perhaps because they have failed to systematically elicit and address both perceptual and practical barriers to adherence. The primary aim of this study is to determine the efficacy of the Supporting UPtake and Adherence (SUPA) intervention. METHODS: This study comprises 2 phases. Phase 1 is an observational cohort study, in which PLWH who are ART naïve and recommended to take ART by their clinician complete a questionnaire assessing their beliefs about ART over 12 months. Phase 2 is a randomised controlled trial (RCT) nested within the observational cohort study to investigate the effectiveness of the SUPA intervention on adherence to ART. PLWH at risk of nonadherence (based on their beliefs about ART) will be recruited and randomised 1:1 to the intervention (SUPA intervention + usual care) and control (usual care) arms. The SUPA intervention involves 4 tailored treatment support sessions delivered by a Research Nurse utilising a collaborative Cognitive Behavioural Therapy (CBT) and Motivational Interviewing (MI) approach. Sessions are tailored to individual needs and preferences based on the individual patient's perceptions and practical barriers to ART. An animation series and intervention manual have been developed to communicate a rationale for the personal necessity for ART and illustrate concerns and potential solutions. The primary outcome is adherence to ART measured using Medication Event Monitoring System (MEMS). Three hundred seventy-two patients will be sufficient to detect a 15% difference in adherence with 80% power and an alpha of 0.05. Costs will be compared between intervention and control groups. Costs will be combined with the primary outcome in cost-effectiveness analyses. Quality adjusted life-years (QALYs) will also be estimated over the follow-up period and used in the analyses. DISCUSSION: The findings will enable patients, healthcare providers and policy makers to make informed decisions about the value of the SUPA intervention. TRIAL REGISTRATION: The trial was retrospectively registered 21/02/2014, ISRCTN35514212 .


Assuntos
Antirretrovirais/uso terapêutico , Terapia Cognitivo-Comportamental/métodos , Infecções por HIV/psicologia , Entrevista Motivacional/métodos , Cooperação do Paciente/psicologia , Adulto , Terapia Cognitivo-Comportamental/economia , Estudos de Coortes , Análise Custo-Benefício , HIV , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Humanos , Masculino , Entrevista Motivacional/economia , Estudos Observacionais como Assunto , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
5.
BMC Psychiatry ; 19(1): 131, 2019 04 30.
Artigo em Inglês | MEDLINE | ID: mdl-31039786

RESUMO

BACKGROUND: Syrians represent the largest group among refugees in Germany. Many of them were exposed to sequential traumatizing events including war, escape and post-migration stressors, which significantly increase the risk to develop symptoms of posttraumatic stress and other mental disorders. However, there is a lack of adequate treatment options for traumatized refugees in Germany. Moreover, their access to psychosocial care is often restricted due to legal regulation, language barriers, and unclear cost coverage. We therefore aim to develop a low-threshold supportive self-help app for Syrian refugees with posttraumatic stress symptoms. By conducting a randomized controlled trial, we further aim to evaluate the apps' efficacy, usability, acceptance, and economic health benefit/cost-effectiveness. METHODS: We will develop a modular, interactive self-help app in Arabic, which will be grounded on cognitive-behavioral models for the treatment of posttraumatic stress. Subsequently, screened positive (i.e., Syrian refugees, 18-65 years old, mild to moderate posttraumatic stress symptomatology as quantified by the Posttraumatic Stress Diagnostic Scale for DSM-5/PDS-5) participants (ideally up to n = 234) will be randomly allocated to an intervention (IG) and control group (CG), respectively. Participants in the IG will gain access to the self-help app for one month, while participants in the CG will receive psychoeducational reading material in form of a comprehensive brochure on traumatization and posttraumatic stress. Measurements are scheduled before the intervention (T0), directly after the intervention (T1, one month later) and three months after the intervention (T2). Using linear mixed effect models, we will investigate change in posttraumatic symptomatology. We will also test for changes in secondary outcomes such as depression, anxiety, and quality of life. Moreover, we will inspect the usability and user acceptance of the app. To evaluate the app in terms of its economic health benefit, the incremental cost-effectiveness ratio will be calculated. DISCUSSION: We plan to make the app freely available to the general public after evaluation. Thus, the app can help to add-on to routine care, which currently lacks sufficient and appropriate treatment options for Syrian refugees. TRIAL REGISTRATION: German Clinical Trials Register/Deutsches Register Klinischer Studien (DRKS). Registration ID: DRKS00013782 . Registered: 06th of July 2018.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Aplicativos Móveis , Refugiados/psicologia , Autocuidado/métodos , Transtornos de Estresse Pós-Traumáticos/psicologia , Transtornos de Estresse Pós-Traumáticos/terapia , Adolescente , Adulto , Idoso , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício/estatística & dados numéricos , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Qualidade de Vida/psicologia , Projetos de Pesquisa , Síria/etnologia , Resultado do Tratamento , Adulto Jovem
6.
BMC Psychiatry ; 19(1): 140, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-31064371

RESUMO

BACKGROUND: Over the past decades research has shown that employment has a positive impact on quality of life, global functioning and recovery in individuals with schizophrenia. However, access to vocational rehabilitation services for this group is limited and unemployment rates remain high. In this study we explore the potential cost-effectiveness of a novel vocational rehabilitation program (The Job Management Program - JUMP) earmarked for individuals with schizophrenia in Norway. METHODS: The JUMP study was a vocational rehabilitation program augmented with either cognitive behaviour therapy or cognitive remediation. In addition to the JUMP protocol, we extracted treatment cost data from comprehensive and mandatory health and welfare registers. The costs over a two-year follow-up period were compared with the costs over the two-year period prior to inclusion in the study. We also compared the cost-effectiveness of JUMP with a treatment as usual group (TAU). RESULTS: We identified significant reductions in inpatient services in the JUMP group, both for those who obtained employment and those who did not. Significant reductions were also found in the TAU group, but adjusted for baseline differences the total cost for JUMP participants were € 10,621 lower than in the TAU group during the follow-up period. CONCLUSION: In addition to supporting individuals with schizophrenia obtain employment, JUMP appears to have reduced the reliance on mental health services, which should be of interest to stakeholders. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01139502 . Retrospectively registered on 6 February 2010.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Remediação Cognitiva/métodos , Análise Custo-Benefício/estatística & dados numéricos , Reabilitação Vocacional/economia , Reabilitação Vocacional/métodos , Esquizofrenia/reabilitação , Adulto , Terapia Cognitivo-Comportamental/economia , Remediação Cognitiva/economia , Análise Custo-Benefício/economia , Emprego/economia , Emprego/psicologia , Emprego/estatística & dados numéricos , Feminino , Humanos , Masculino , Noruega , Estudos Retrospectivos , Esquizofrenia/economia , Resultado do Tratamento
7.
Medicine (Baltimore) ; 98(18): e15305, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31045765

RESUMO

BACKGROUND/OBJECTIVE: Evidence from previous research has shown that the incidence of aphasia following a stroke is high in Nigeria and other countries, and there is a call for intervention programs. The objective of the current study was to investigate the efficacy of cognitive behavior language therapy (CBLT) on aphasia following a stroke. METHODS: The study was designed as a group randomized trial, which involved treatment and no-treatment control procedures. The participants of the study were 86 patients who had experienced aphasia following a stroke. The Porch Index of Communicative Ability (PICA) and Speech-Language Unhelpful Thoughts and Beliefs Scale (SLUTBS) were the measures used in the study. The repeated measures analysis of variance procedure, with Partial eta squared (Equation is included in full-text article.), adjusted R, mean, standard deviation, and upper/lower limit was followed in analyzing the data collected in the study. RESULTS: The CBLT intervention significantly reduced aphasia following a stroke and significantly reduced speech-language and unhelpful thought and beliefs among aphasic stroke patients exposed to the treatment intervention when compared with the no-treatment control group. CONCLUSION: Based on the findings of the study, language educators, speech and language pathologists and therapists in education institutions, hospitals, and rehabilitation centers should adopt the principles of CBLT used in the current study to help them improve communication ability among aphasia stroke patients.


Assuntos
Afasia/terapia , Terapia Cognitivo-Comportamental/métodos , Terapia da Linguagem/métodos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/terapia , Afasia/etiologia , Afasia/reabilitação , Terapia Cognitivo-Comportamental/economia , Terapia Cognitivo-Comportamental/educação , Currículo/normas , Feminino , Humanos , Terapia da Linguagem/economia , Masculino , Pessoa de Meia-Idade , Nigéria/epidemiologia , Qualidade de Vida , Projetos de Pesquisa , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/psicologia , Reabilitação do Acidente Vascular Cerebral/métodos
8.
BMC Cancer ; 19(1): 462, 2019 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-31096934

RESUMO

BACKGROUND: Blended cognitive behaviour therapy (bCBT) is an effective treatment for fear of cancer recurrence (FCR) in curatively-treated breast, colorectal and prostate cancer survivors with high FCR. However, long-term outcomes are unknown. This study investigated the long-term efficacy and cost-effectiveness of bCBT compared with care as usual (CAU). METHODS: Eighty-eight cancer survivors with high FCR (Cancer Worry Scale ≥14) were randomly assigned to bCBT (n = 45) or CAU (n = 43). Data were collected at baseline and at three, nine and fifteen months from baseline and analysed by modified intention-to-treat. Efficacy was investigated with linear mixed-effects models. Cost-effectiveness was investigated from a societal perspective by comparing costs with quality-adjusted life-years (QALYs). RESULTS: Participants who received bCBT reported significantly lower FCR compared with CAU (mean difference of - 1.787 [95% CI -3.251 to - 0.323, p = 0.017] at 15 months follow-up), and proportionally greater self-rated and clinically significant improvement at each follow-up measurement. Total QALYs were non-significantly different between conditions when adjusted for utility score baseline differences (0.984 compared to 0.957, p = 0.385), while total costs were €631 lower (95% CI -1737 to 2794, p = 0.587). Intervention costs of bCBT were €466. The incremental cost-effectiveness ratio amounted to an additional €2049 per QALY gained, with a 62% probability that bCBT is cost-effective at a willingness to pay (WTP) threshold of €20,000 per QALY. Results were confirmed in sensitivity analyses. CONCLUSIONS: bCBT for cancer survivors with FCR is clinically and statistically more effective than CAU on the long-term. In addition, bCBT is a relatively inexpensive intervention with similar costs and QALYs as CAU. TRIAL REGISTRATION: The RCT was registered in the Dutch National Trial Register ( NTR4423 ) on 12-Feb-2014. This abstract was previously presented at the International Psycho-Oncology Society conference of 2018 and published online. (Psycho-oncology, 27(S3):8-55; 2018).


Assuntos
Sobreviventes de Câncer/psicologia , Terapia Cognitivo-Comportamental/economia , Medo , Recidiva Local de Neoplasia/psicologia , Neoplasias/patologia , Idoso , Neoplasias da Mama/patologia , Neoplasias da Mama/psicologia , Neoplasias Colorretais/patologia , Neoplasias Colorretais/psicologia , Análise Custo-Benefício , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/psicologia , Neoplasias da Próstata/patologia , Neoplasias da Próstata/psicologia , Resultado do Tratamento
9.
Lancet Psychiatry ; 6(5): 391-402, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30952568

RESUMO

BACKGROUND: Opioid use disorder is a chronic, debilitating, and costly disorder that has increased in prevalence in many countries, with an associated sharp rise in mortality. Maintenance opioid agonist therapy is the first-line treatment, but many patients do not stop using illicit or non-prescribed drugs concomitantly. We aimed to test the efficacy and cost-effectiveness of a personalised psychosocial intervention implemented with a toolkit of behaviour-change techniques as an adjunct to opioid agonist therapy. METHODS: We did a pragmatic, open-label, randomised controlled trial at a specialist UK National Health Service community addictions clinic in London, UK. Eligible patients were aged 18 years or older, met criteria for opioid or cocaine dependence, or both, in the past 12 months, and voluntarily sought continued oral maintenance opioid agonist therapy, which they had been prescribed for at least 6 weeks. All participants were treatment resistant (ie, had used illicit or non-prescribed opioids or cocaine on one or more days in the past 28 days at study screening, which was verified by positive urine drug screen). Participants were allocated (1:1) by a web-accessed randomisation sequence (stratified by opioid agonist medication, current cocaine use, and current rug use) to receive a personalised psychosocial intervention (comprising a flexible toolkit of psychological-change methods, including contingency management to reinforce abstinence, recovery activities, and clinic attendance) in addition to treatment as usual, or treatment as usual only (control group). The primary outcome was treatment response at 18 weeks, which was defined as abstinence from illicit and non-prescribed opioids and cocaine in the past 28 days, as measured with treatment outcomes profiles and urine drug screening. Taking a societal cost perspective, we did an evaluation of cost-effectiveness with a wide range of willingness-to-pay values for a unit improvement in the probability of treatment response. We also calculated quality-adjusted life-years (QALYs). Efficacy was analysed in a modified-intention-to-treat population, including all participants who were randomly allocated but excluding those who had previously completed the intervention. This trial is registered with ISRCTN, number ISRCTN69313751. The trial is completed. FINDINGS: Between June 7, 2013, and Dec 21, 2015, we randomly allocated 136 participants to the psychosocial intervention group and 137 to the control group. The trial database was locked on April 19, 2017. Three patients (one in the psychosocial intervention group and two in the control group) who were re-randomised in error were excluded from the analysis. 22 (16%) of 135 patients in the psychosocial intervention group had a treatment response, compared with nine (7%) of 135 in the control group (adjusted log odds 1·20 [95% CI 0·01-2·37]; p=0·048). The psychosocial intervention had a higher probability of being cost-effective than treatment as usual. There was a probability range of 47-87% for willingness-to-pay thresholds of £0-1000 for a unit improvement in the probability of treatment response. QALYs were higher in the psychosocial intervention group than in the control group (mean difference 0·048 [95% CI 0·016-0·080]; p=0·004) in adjusted analyses, with 60% and 67% probabilities of cost-effectiveness at the UK National Institute for Health and Care Excellence's willingness-to-pay thresholds of £20 000 and £30 000 per QALY, respectively. The number of adverse events was similar between groups, and no severe adverse events in either group were judged to be treatment related. One participant in the control group was hospitalised with drug-injection-related sepsis and died. INTERPRETATION: In maintenance opioid agonist therapy, an adjunctive personalised psychosocial intervention in addition to standard therapy was efficacious and cost-effective compared with standard therapy alone at helping treatment-resistant patients abstain from using illicit and non-prescribed opioids and cocaine. FUNDING: Indivior.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Terapia Combinada/economia , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/terapia , Adulto , Analgésicos Opioides/agonistas , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício , Feminino , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos/economia , Transtornos Relacionados ao Uso de Opioides/economia , Medicina de Precisão , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento , Reino Unido
10.
Trials ; 20(1): 91, 2019 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-30700318

RESUMO

BACKGROUND: The development of efficacious, cost-effective, and widely accessible programs for the prevention of eating disorders (EDs) is crucial in order to reduce the ED-related burden of illness. Programs using dissonance-based and cognitive behavioral approaches are most effective for the selective prevention of ED. Internet-based delivery is assumed to maximize the reach and impact of preventive efforts. However, the current evidence for Internet-based ED prevention is limited. The present trial evaluates the efficacy and cost-effectiveness of two new interventions (based on dissonance theory and principles of cognitive behavioral therapy (CBT)) that are implemented as add-ons to the existing Internet-based ED prevention program ProYouth. METHODS: The trial is one of five sub-projects of the German multicenter consortium ProHEAD. It is a three-arm, parallel, randomized controlled superiority trial. Participants will be randomized to (1) the online program ProYouth (active control condition) or (2) ProYouth plus a structured dissonance-based module or (3) ProYouth plus a CBT-based chat group intervention. As part of ProHEAD, a representative school-based sample of N = 15,000 students (≥ 12 years) will be screened for mental health problems. N = 309 participants at risk for ED (assessed with the Weight Concerns Scale (WCS) and the Short Evaluation of Eating Disorders (SEED)) will be included in the present trial. Online assessments will be conducted at baseline, at end of intervention (6 weeks), at 6 months follow-up, and - as part of ProHEAD - at 12 and 24 months follow-up. The primary outcome is ED-related impairment (assessed with the Child version of the Eating Disorder Examination-Questionnaire (ChEDE-Q)) at the end of the intervention. Secondary outcomes include ED-related symptomatology at follow-up, ED-related stigma, ED-related help-seeking, and acceptance of and compliance with the interventions. For the health economic evaluation data on costs of the interventions, healthcare utilization and health-related quality of life will be assessed. DISCUSSION: This is the first study augmenting a flexible prevention approach such as ProYouth with structured evidence-based modules in order to overcome some of the key limitations in the current practice of ED prevention. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), DRKS00014679 . Registered on 25 April 2018.


Assuntos
Comportamento do Adolescente , Comportamento Infantil , Terapia Cognitivo-Comportamental/métodos , Comportamento Alimentar , Transtornos da Alimentação e da Ingestão de Alimentos/prevenção & controle , Hábitos , Internet , Terapia Assistida por Computador/métodos , Adolescente , Fatores Etários , Criança , Terapia Cognitivo-Comportamental/economia , Dissonância Cognitiva , Análise Custo-Benefício , Estudos de Equivalência como Asunto , Transtornos da Alimentação e da Ingestão de Alimentos/diagnóstico , Transtornos da Alimentação e da Ingestão de Alimentos/economia , Transtornos da Alimentação e da Ingestão de Alimentos/psicologia , Feminino , Alemanha , Custos de Cuidados de Saúde , Humanos , Internet/economia , Masculino , Estudos Multicêntricos como Assunto , Inquéritos e Questionários , Terapia Assistida por Computador/economia , Fatores de Tempo , Resultado do Tratamento
12.
BMC Med ; 17(1): 16, 2019 01 23.
Artigo em Inglês | MEDLINE | ID: mdl-30670044

RESUMO

BACKGROUND: It is challenging to engage repeat users of unscheduled healthcare with severe health anxiety in psychological help and high service costs are incurred. We investigated whether clinical and economic outcomes were improved by offering remote cognitive behaviour therapy (RCBT) using videoconferencing or telephone compared to treatment as usual (TAU). METHODS: A single-blind, parallel group, multicentre randomised controlled trial was undertaken in primary and general hospital care. Participants were aged ≥18 years with ≥2 unscheduled healthcare contacts within 12 months and scored >18 on the Health Anxiety Inventory. Randomisation to RCBT or TAU was stratified by site, with allocation conveyed to a trial administrator, research assessors masked to outcome. Data were collected at baseline, 3, 6, 9 and 12 months. The primary outcome was change in HAI score from baseline to six months on an intention-to-treat basis. Secondary outcomes were generalised anxiety, depression, physical symptoms, function and overall health. Health economics analysis was conducted from a health service and societal perspective. RESULTS: Of the 524 patients who were referred and assessed for trial eligibility, 470 were eligible and 156 (33%) were recruited; 78 were randomised to TAU and 78 to RCBT. Compared to TAU, RCBT significantly reduced health anxiety at six months, maintained to 9 and 12 months (mean change difference HAI -2.81; 95% CI -5.11 to -0.50; P = 0.017). Generalised anxiety, depression and overall health was significantly improved at 12 months, but there was no significant change in physical symptoms or function. RCBT was strictly dominant with a net monetary benefit of £3,164 per participant at a willingness to pay threshold of £30,000. No treatment-related adverse events were reported in either group. CONCLUSIONS: RCBT may reduce health anxiety, general anxiety and depression and improve overall health, with considerable reductions in health and informal care costs in repeat users of unscheduled care with severe health anxiety who have previously been difficult to engage in psychological treatment. RCBT may be an easy-to-implement intervention to improve clinical outcome and save costs in one group of repeat users of unscheduled care. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov on 19 Nov 2014 with reference number NCT02298036.


Assuntos
Ansiedade/terapia , Terapia Cognitivo-Comportamental/métodos , Telemedicina/métodos , Adolescente , Adulto , Idoso , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego , Telemedicina/economia , Resultado do Tratamento
13.
Expert Rev Pharmacoecon Outcomes Res ; 19(3): 331-340, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30324818

RESUMO

BACKGROUND: This study evaluated the cost-utility of telephone-based cognitive behavioral therapy (TB-CBT) (experimental arm) in comparison with a placebo-befriending (control arm) program in COPD participants with mild to severe depression and/or anxiety. METHODS: The decision rule was based on willingness-to-pay if there is an increased unit of effectiveness (a quality-adjusted life year [QALY] gain) and an increase in cost, and willingness-to-accept (WTA) if there is a reduced unit of effectiveness (a QALY loss) and decrease in cost (a cost-saving). RESULTS: TB-CBT group was associated with a reduction in the incremental cost of AUS-$407.3 (p < 0.001, SE:34.1) plus a negative, nonsignificant incremental QALY gain of -0.008 (SE:0.011) per patient compared to control group. The point estimate of the mean incremental cost-utility ratio was AUS$50,284.0 cost saving per QALY sacrificed (the high value associated with small QALY value in the denominator). Ninety-five percent CI was AUS$13,426 cost sacrificed to AUS$32,018 cost gain (lower values associated with larger QALY values in the denominator). If the societal's minimum (flooring threshold) WTA is AUS$64,000 per QALY forgone, the probability of TB-CBT being cost-effective was 42% Conclusions: This study showed that TB-CBT can be recommended as a cost-saving and preventive approach over usual care plus befriending program.


Assuntos
Ansiedade/terapia , Terapia Cognitivo-Comportamental/métodos , Depressão/terapia , Doença Pulmonar Obstrutiva Crônica/terapia , Idoso , Ansiedade/psicologia , Terapia Cognitivo-Comportamental/economia , Redução de Custos , Análise Custo-Benefício , Depressão/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Doença Pulmonar Obstrutiva Crônica/psicologia , Anos de Vida Ajustados por Qualidade de Vida , Índice de Gravidade de Doença , Telefone , Resultado do Tratamento
14.
PLoS One ; 13(11): e0206236, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30419038

RESUMO

BACKGROUND: In schizophrenia spectrum disorders, negative symptoms (e.g. social withdrawal) may persist after initial treatment with antipsychotics, much affecting the quality of life (QOL) of patients. This health-economic study evaluated if a dedicated form of cognitive behaviour therapy for social activation (CBTsa) would reduce negative symptoms and improve QOL in an economically sustainable way. METHODS: A health-economic evaluation was conducted alongside a single-blind randomised controlled trial in two parallel groups: guideline congruent treatment as usual (TAU; n = 50) versus TAU augmented with adjunct CBTsa (n = 49). Outcomes were PANSS negative symptom severity and EQ-5D quality adjusted life years (QALYs) gained. The health-economic evaluation was conducted both from the societal and the health sector perspective. RESULTS: Both conditions showed improvement in the respective outcomes over the follow-up period of six months, but QALY gains were significantly higher in the CBTsa condition compared to the TAU condition. Treatment response rate (i.e. ≥ 5-point decrease on the PANSS) was not significantly different. However, the add-on CBT intervention was associated with higher costs. This did not support the idea that CBTsa is a cost-effective adjunct. Various sensitivity analyses attested to the robustness of these findings. CONCLUSIONS: In the Dutch context where TAU for psychosis is guideline congruent and well implemented there appears no added value for adjunct CBTsa. In other settings where the treatment for the schizophrenia spectrum disorders solely relies on antipsychotics, add-on CBTsa may lead to clinically superior outcomes, but it should still be evaluated if adjunct CBTsa therapy is a cost-effective alternative. TRIAL REGISTRATION: ClinicalTrials.gov registry under NCT03217955.


Assuntos
Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício/economia , Transtornos Psicóticos/tratamento farmacológico , Esquizofrenia/tratamento farmacológico , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Psicóticos/economia , Transtornos Psicóticos/epidemiologia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Esquizofrenia/economia , Esquizofrenia/epidemiologia , Método Simples-Cego , Comportamento Social
15.
Lancet Child Adolesc Health ; 2(11): 792-801, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30241993

RESUMO

BACKGROUND: Paediatric anxiety disorders are associated with substantial disability and long-term adverse consequences, but only a small proportion of affected children have access to evidence-based treatment. Internet-delivered cognitive behavioural therapy (ICBT) could help increase accessibility but needs further rigorous assessment. We aimed to assess the efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders. METHODS: We did a single-blind randomised controlled trial in a clinical research unit within the Child and Adolescent Mental Health Services in Stockholm (Sweden). Eligible participants were children aged 8-12 years with a diagnosis of a principal anxiety disorder (seperation anxiety disorder, generalised anxiety disorder, specific phobia, social anxiety disorder, or panic disorder) of at least moderate severity. We randomly allocated participants (1:1) to ICBT or internet-delivered child-directed play, an active comparator aimed to improve parent-child relationships and increase a child's self-esteem without directly targeting anxiety. Block sizes for the randomisation varied between four and six and were generated using a computer random-number generator, and the allocation was concealed from the researchers by opaque sealed envelopes. Both treatment programmes comprised 12 modules presented over 12 weeks with weekly asynchronous online therapist support, and consisted of texts, films, illustrations, and exercises. The primary outcome was severity rating of the principal anxiety disorder 12-weeks post-treatment, via the Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders-IV (a rating of at least 4 corresponds to meeting the criteria for the principal diagnosis), assessed by clinicians masked to treatment allocation. All participants were included in the primary analysis (intention-to-treat). This trial is registered at ClinicalTrials.gov, number NCT02350257. FINDINGS: Between March 11, 2015, and Oct 21, 2016, 131 participants were recruited and allocated to either ICBT (n=66) or internet-delivered child-directed play (n=65). The clinician-assessed severity rating of the principal anxiety disorder improved significantly after the 12-weeks treatment period for participants in both ICBT (within-group effect size 1·22, 95% CI 0·78-1·65) and the active control (0·72, 0·44-1·00) groups. However, greater improvement was seen with ICBT than with the active control (estimated mean difference 0·79, 95% CI 0·42-1·16, p=0·002; between-group effect size 0·77, 95% CI 0·40-1·15). 29 (48%) participants in the ICBT group no longer had their principal diagnosis, compared to nine (15%) in the active control group (odds ratio 5·41, 95% CI 2·26 to 12·90, p<0·0001); the number needed to treat for ICBT to gain one additional participant in remission was three (95% CI 2·85 to 3·15). ICBT resulted in an average societal-cost saving of €493·05 (95% CI 477·17 to 508·92) per participant. No severe adverse events were reported. INTERPRETATION: ICBT is an efficacious and cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care. FUNDING: The Swedish Research Council for Health, Working Life and Welfare, and Stockholm County Council.


Assuntos
Transtornos de Ansiedade/terapia , Terapia Cognitivo-Comportamental/economia , Terapia Cognitivo-Comportamental/métodos , Análise Custo-Benefício , Internet , Transtornos de Ansiedade/diagnóstico , Criança , Feminino , Humanos , Masculino , Relações Pais-Filho , Autoimagem , Método Simples-Cego
16.
Int Clin Psychopharmacol ; 33(6): 334-348, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30113928

RESUMO

Established treatments for obsessive compulsive disorder (OCD) include cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication. Combined treatment may outperform monotherapy, but few studies have investigated this. A total of 49 community-based adults with OCD were randomly assigned to CBT, SSRI, or SSRI+CBT. Sertraline (50-200 mg/day) was given as the SSRI for 52 weeks. A 16-h-manualized individual CBT was delivered over 8 weeks with four follow-up sessions. Assessors were 'blinded' to treatment allocation. A preliminary health economic evaluation was conducted. At week 16, combined treatment (n=13) was associated with the largest improvement, sertraline (n=7) the next largest and CBT (n=9) the smallest on the observed case analysis. The effect size (Cohen's d) comparing the improvement in Yale Brown Obsessive Compulsive Scale on CBT versus combined treatment was -0.39 and versus sertraline was -0.27. Between 16 and 52 weeks, the greatest clinical improvement was seen with sertraline, but participant discontinuation prevented reliable analysis. Compared with sertraline, the mean costs were higher for CBT and for combined treatment. The mean Quality Adjusted Life Year scores for sertraline were 0.1823 (95% confidence interval: 0.0447-0.3199) greater than for CBT and 0.1135 (95% confidence interval: -0.0290-0.2560), greater than for combined treatment. Combined treatment appeared the most clinically effective option, especially over CBT, but the advantages over SSRI monotherapy were not sustained beyond 16 weeks. SSRI monotherapy was the most cost-effective. A definitive study can and should be conducted.


Assuntos
Terapia Cognitivo-Comportamental/economia , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Terapia Combinada/economia , Terapia Combinada/estatística & dados numéricos , Transtorno Obsessivo-Compulsivo/tratamento farmacológico , Inibidores de Captação de Serotonina/economia , Inibidores de Captação de Serotonina/uso terapêutico , Adolescente , Adulto , Idoso , Análise Custo-Benefício/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Transtorno Obsessivo-Compulsivo/economia , Anos de Vida Ajustados por Qualidade de Vida , Método Simples-Cego , Adulto Jovem
17.
BMJ Open ; 8(8): e025031, 2018 08 17.
Artigo em Inglês | MEDLINE | ID: mdl-30121618

RESUMO

INTRODUCTION: Specific phobias (intense, enduring fears of an object or situation that lead to avoidance and severe distress) are highly prevalent among children and young people. Cognitive-behavioural therapy (CBT) is a well-established, effective intervention, but it can be time consuming and costly because it is routinely delivered over multiple sessions during several months. Alternative methods of treating severe and debilitating phobias in children are needed, like one-session treatment (OST), to reduce time and cost, and to prevent therapeutic drift and help children recover quickly. Our study explores whether (1) outcomes with OST are 'no worse' than outcomes with multisession CBT, (2) OST is acceptable to children, their parents and the practitioners who use it and (3) OST offers good value for money to the National Health Service (NHS) and to society. METHOD: A pragmatic, non-inferiority, randomised controlled trial will compare OST with multisession CBT-based therapy on their clinical and cost-effectiveness. The primary clinical outcome is a standardised behavioural task of approaching the feared stimulus at 6 months postrandomisation. The outcomes for the within-trial cost-effectiveness analysis are quality-adjusted life years based on EQ-5D-Y, and individual-level costs based of the intervention and use of health and social service care. A nested qualitative evaluation will explore children's, parents' and practitioners' perceptions and experiences of OST. A total of 286 children, 7-16 years old, with DSM-IV diagnoses of specific phobia will be recruited via gatekeepers in the NHS, schools and voluntary youth services, and via public adverts. ETHICS AND DISSEMINATION: The trial received ethical approval from North East and York Research Ethics Committee (Reference: 17/NE/0012). Dissemination plans include publications in peer-reviewed journals, presentations in relevant research conferences, local research symposia and seminars for children and their families, and for professionals and service managers. TRIAL REGISTRATION NUMBER: ISRCTN19883421;Pre-results.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Transtornos Fóbicos/terapia , Adolescente , Criança , Protocolos Clínicos , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício , Feminino , Humanos , Masculino , Transtornos Fóbicos/economia , Resultado do Tratamento
18.
BMC Psychiatry ; 18(1): 265, 2018 08 23.
Artigo em Inglês | MEDLINE | ID: mdl-30139332

RESUMO

BACKGROUND: Mental well-being could be promoted and protected by positive psychology (PP) based interventions. Such interventions may be appealing for people at risk of anxiety and depressive disorders, but health-economic evaluations are scarce. The aim was to examine the cost-effectiveness of a PP intervention. METHODS: Participants with suboptimal levels of mental well-being were randomly assigned to an email guided PP-intervention (n = 137) or a wait-list control group (n = 138) with access to usual care (UC). At baseline and 6 months follow-up, data were collected on health care costs. Outcomes of interest were flourishing mental health and treatment response on anxiety and depressive symptoms. RESULTS: Bootstrapped mean incremental cost-effectiveness ratios were €2359 ($2899) for flourishing, €2959 ($3637) for anxiety and €2578 ($3168) for depression, suggesting appreciable health gains for low additional costs. At a willingness to pay ceiling of €10,000 ($12,290) for a treatment response, the probability that the intervention is deemed cost-effective ranged between 90 and 93%. CONCLUSIONS: The guided PP intervention appears to be a promising strategy as seen from both a public health and a health-economic perspective, especially when there is some willingness to pay. When the PP-intervention is scaled up, then outcome monitoring is recommended to better guarantee the longer term cost-effectiveness of the intervention. TRIAL REGISTRATION: The Netherlands National Trial Register NTR4297. Registered on 29 November 2013. The NTR is part of the WHO Primary Registries.


Assuntos
Transtornos de Ansiedade/terapia , Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo/terapia , Serviços de Saúde Mental/economia , Otimismo/psicologia , Adulto , Transtornos de Ansiedade/economia , Terapia Cognitivo-Comportamental/economia , Análise Custo-Benefício , Transtorno Depressivo/economia , Feminino , Custos de Cuidados de Saúde , Promoção da Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Apoio Social , Listas de Espera
19.
Br J Psychiatry ; 212(4): 199-206, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-30071909

RESUMO

BACKGROUND: Web-based interventions are effective in reducing depression. However, the evidence for the cost-effectiveness of these interventions is scarce.AimsThe aim is to assess the cost-effectiveness of a web-based intervention (GET.ON M.E.D.) for individuals with diabetes and comorbid depression compared with an active control group receiving web-based psychoeducation. METHOD: We conducted a cost-effectiveness analysis with treatment response as the outcome and a cost-utility analysis with quality-adjusted life-years (QALYs) alongside a randomised controlled trial with 260 participants. RESULTS: At a willingness-to-pay ceiling of €5000 for a treatment response, the intervention has a 97% probability of being regarded as cost-effective compared with the active control group. If society is willing to pay €14 000 for an additional QALY, the intervention has a 51% probability of being cost-effective. CONCLUSIONS: This web-based intervention for individuals with diabetes and comorbid depression demonstrated a high probability of being cost-effective compared with an active control group.Declaration of interestS.N., D.D.E., D.L., M.B. and B.F. are stakeholders of the Institute for Online Health Trainings, which aims to transfer scientific knowledge related to this research into routine healthcare.


Assuntos
Terapia Cognitivo-Comportamental , Análise Custo-Benefício , Depressão , Transtorno Depressivo , Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Telemedicina , Adulto , Terapia Cognitivo-Comportamental/economia , Terapia Cognitivo-Comportamental/métodos , Comorbidade , Depressão/economia , Depressão/epidemiologia , Depressão/terapia , Transtorno Depressivo/economia , Transtorno Depressivo/epidemiologia , Transtorno Depressivo/terapia , Diabetes Mellitus Tipo 1/economia , Diabetes Mellitus Tipo 1/epidemiologia , Diabetes Mellitus Tipo 2/economia , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Telemedicina/economia , Telemedicina/métodos
20.
Int J Technol Assess Health Care ; 34(4): 400-409, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30047357

RESUMO

OBJECTIVES: The aim of this study was to evaluate the cost-effectiveness of exposure in vivo (EXP, a cognitive-behavioral treatment targeting pain-related fear) in Complex Regional Pain Syndrome Type I (CRPS-I), as compared to pain-contingent physical therapy (PPT). METHODS: Data from a randomized controlled trial were used to compare the cost-effectiveness of EXP versus PPT from a societal perspective. Intervention costs, other healthcare costs, costs to patient and family, and productivity losses were included. The main outcomes were changes in the SF-36 physical component scale and quality-adjusted life-years. Changes were followed until 6 months after treatment. Uncertainty was estimated using nonparametric bootstrap analysis, cost-effectiveness acceptability curves and cost-effectiveness planes. Sensitivity analyses were performed to check robustness of findings. RESULTS: Forty-six patients were randomized and thirty-eight completed the study. Over 6 months, EXP resulted in greater improvement in physical health-related quality of life and quality-adjusted life-years than PPT. Despite higher initial treatment costs, EXP showed a tendency to reduce all costs compared with PPT; healthcare costs were significantly reduced. Furthermore, the cost-effectiveness planes were in favor of EXP. Sensitivity analyses, for different program costs and complete cases only, confirmed robustness of these findings. CONCLUSIONS: EXP, a cognitive-behavioral treatment, seems more cost-effective than PPT in CRPS patients with pain-related fear. The initial higher costs for EXP are offset by a long-term reduction of costs for healthcare use, and a tendency to lower work absenteeism and reduced societal costs. Due to low sample sizes, replication of findings is required to confirm results.


Assuntos
Terapia Cognitivo-Comportamental/economia , Terapia Cognitivo-Comportamental/métodos , Síndromes da Dor Regional Complexa/terapia , Modalidades de Fisioterapia/economia , Adulto , Fatores Etários , Síndromes da Dor Regional Complexa/reabilitação , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econométricos , Manejo da Dor/economia , Manejo da Dor/métodos , Qualidade de Vida , Fatores Sexuais , Fatores Socioeconômicos
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