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Table 4 Methodological considerations and cost-effectiveness results

From: Identifying and assessing the benefits of interventions for postnatal depression: a systematic review of economic evaluations

Lead author (Year) Intervention Perspective (reasons) Time horizon used in economic evaluation (reasons) Discounting Key cost-effectiveness results
RCT or cohort-based economic evaluations
Boath (2003) [39] PBDU customised treatment Societal 6 months (practical considerations, budgetary constraints) Costs: 6% “The current treatment of postnatal depression is dominated on the grounds of cost-effectiveness by PBDU treatment. The move from RPC to PBDU would incur an additional cost expended per successfully treated woman of £1945.”
Dukhovny (2013) [27] Telephone-based peer support intervention, access to standard postpartum care Societal (US and Canadian guidelines) Third-party payer, Healthcare, Family perspective 12 weeks (RCT time horizon) No** The intervention was found to be cost-effective. ICER: CAD $10,009 per case of PND averted There is 95% probability that the program would cost less than CAD $20,196 per PND case averted
Hiscock (2007) [26] Individual structured maternal and child health consultations, a choice of behavioural interventions, ‘controlled crying’ or ‘camping out’ NHS/PSS* 10, 12 months No Benefits Infant sleep problems At 10 months, 56% of intervention and 68% of control mothers reported infant sleep problems (OR 0.61, p = 0.04); At 12 months, this fell to 39% vs 55% (OR 0.53, p = 0.007). EPDS scores Intervention mothers had lower mean EPDS scores than controls at 12 months (5.9 vs 7.2, p = 0.001) and higher mental health (SF-12) scores at both 10 months (48.1 vs 45.0, p = 0.001) and 12 months (49.7 vs 46.1, p = 0.001). Costs Intervention: £96.93 (SD, £249.37) Control: £116.79 (SD, £ 330.31) Mean difference: £19.44 (95% CI £283.70 to £44.81, p = 0.55)
MacArthur (2003) [31] Redesigned model of community postnatal care (midwifery-led) Healthcare 12 months No** “The cost-consequences analysis established that the costs of the intervention and control care were broadly equivalent. The intervention care costing at a maximum £81.90 more per woman to deliver, but possibly representing a saving of £78.30 per woman, depending on assumptions used.”
Morrell (2000) [32] Community midwifery support worker Healthcare 6 weeks (Valid use of EPDS enabling comparability with other trials) Costs: 5% Given that health outcomes were similar for both groups, the economic analysis is limited to a comparison of costs between the intervention and control groups. Mean total cost to the NHS at 6 weeks (primary analysis) Intervention group: £635 (SD, £326) The control group: £456 (SD, £291) Mean difference: £180 (95% CI, £126, £232, p = 0.001).
Morrell (2009) [37] Health visitor trained to identify and deliver CBA or person-centred approach NHS/PSS (NICE guidelines) 6 months No** The intervention dominated the comparator for at-risk women at 6 months (primary analysis). However, a significant difference was not observed in the number of QALYs gained in the intervention groups compared to the control group and there was uncertainty associated with the cost and QALY pairs. The probability of CBT being cost-effective was just over 70%***
Petrou (2006) [33] Counselling and support package by trained health visitors Healthcare 18 months (RCT time period) Outcomes: 1.5% Costs: 6% The intervention is cost-effective compared to RPC. ICER £43.1 per month of PND avoided. The probability that the intervention is cost-effective exceeds 70% once decision makers express a willingness to invest £1000 to prevent each month of PND.
Price (2015) [29] Enhanced engagement in home visiting via motivational interviewing and brief intervention (CBT and Interpersonal Therapy) Service providers* 12 weeks No Benefits “A decrease in depressive symptoms associated with the intervention that approached statistical significance (p = 0.0600). Significant increase in perceived social support (t = 3.35, p = 0.0027).” Mean Costs Usual care: $158.30 per participant Enhanced Engagement: $147.50 per participant
Sembi (2016) [41] Telephone peer support Healthcare 6 months No Benefits (primary outcomes) No significant differences between-subjects and improvement in mother-infant interaction. Costs Mean cost of the combined use of NHS resources For the intervention group: £800.67 (SD, £761.74) For standard care group: £1537.80 (SD, £1936.37). It was not possible to conduct a cost-effectiveness analysis due to the small number of patients.
Wiggins (2004) [35] Health visitor support or Community group support Healthcare, Patients 12,18 months 6% (costs) Benefits There was no clear difference in any of the primary outcomes. Maternal depression: Fewer women in the combined intervention group scored over the depression threshold on the EPDS (−3%) than the control group Mean Costs The Support Health Visitor intervention emerged as a relatively expensive intervention to implement compared with the Community Group Support intervention. Support Health Visitor = £3255 (SD, £2253) Community Group Support: £3231 (SD, £3323) Control group: £2915 (SD, £2349)
Model-based economic evaluations
Battye (2012) [30] Befriending service (telephone helpline and one-to-one support by trained ‘befriender’ volunteers) Societal, public sector (demonstrate value to society and healthcare) Outcomes 3, 6 and 30 years Costs 1 year 3.5% The befriending service was cost-beneficial to both society and the state. Societal perspective For every £1 invested, the estimated SROI: ▪ £3 over the short term ▪ £4 over the medium term ▪ £6.50 over the longer term Public sector perspective For every £1 invested, the estimated SROI: ▪ £0.20 over the short term ▪ £0.20 over the medium term ▪ £1.50 over the longer term
Bauer (2011) [42] Universal health visiting (postnatal screening using EPDS and treatment [CBT + antidepressant]) Societal* 12 months No Health visiting intervention provided a positive net benefit. ICER £4500 per QALY gained Net monetary benefits £640 per mother (at WTP threshold of £20,000). By extrapolation, this amounts to around £300 million for England.
Campbell (2008) [28] Routine screening programme (using PHQ-2) and treatments according to severity of PND. Healthcare 12 months No** The proposed routine screening programme appears to be highly cost-effective compared to the current practice from a government perspective. ICERs • NZ $287 per additional case detected • NZ $400 per additional case resolved • NZ $3461 per additional QALY gained
Hewitt (2009) [36] Identification 1.EPDS 2. BDI Treatments 1. Structured psychological therapy 2. Listening visit (Both with preceding additional care) NHS/PSS 12 months No** Identification ICER The identification strategies were not cost-effective compared to the current practice. EPDS at a cut point of 16: 3£41,204 per QALY gained. Other cut points and BDI cut point 10 were either dominated or had ICERs higher than that of EPDS cut point 16. At each of the three WTP thresholds considered (£20,000, £30,000 and £40,000), the strategy with the highest individual probability of being cost-effective was routine case detection. Treatment Structured psychological therapy was a cost effective treatment** but listening home visits was not cost-effective compared to the current practice. ICER Structured psychological therapy: £17,481 per QALY gained Listening home visits: £66,275 per QALY gained There was 50% probability that structured psychological therapy would be cost-effective at a WTP threshold of £20,000 per QALY gained.
NCCMH (2014)[38] Identification 1. EPDS only 2. Whooley questions followed by EPDS 3. Whooley questions followed by PHQ-9 Treatment 1. Facilitated self-help based on CBT principles 2. Listening visits (Both in addition to standard postnatal care) NHS/PSS (NICE guidelines) Identification 12 months Treatment 12 months 7 weeks No** Identification The ‘Whooley questions’ followed by PHQ-9 was estimated to be the most cost-effective identification strategy, however, well above the NICE threshold**. ICER Whooley questions followed by EPDS versus Whooley questions followed by PHQ-9: £45,593 per QALY gained Treatment Facilitated self-help compared with standard care was overall more effective and more costly. ICER Facilitated self-help: £2269 per additional woman improving and not relapsing at the end of the model, or £13,324 per QALY gained. The probability of facilitated self-help being cost effective is 0.59 to 0.72***.
Stevenson (2010) [40] Group CBT NHS/PSS (NICE guidelines) 12 months No** The group CBT compared with RPC was not found to be cost-effective.*** ICER CBT: £46,462 per QALY gained (95% CI, £37,008 to £60,728).
Taylor (2014) [34] Social support (e.g. advocacy, befriending) Societal* (to determine value to society) 12 months-over a lifetime 3.5% (outcomes) Estimated average direct financial cost of providing support: £2230 per woman. Estimated benefit Using SF-6D: £591–£887 per woman treated Using EQ-5D: £1302–£1954 per woman treated
  1. *Not explicitly stated by authors
  2. **Reasons provided: due to small time horizon
  3. ***At a willingness-to-pay threshold of £20,000-£30,000/QALY gained
  4. BDI Beck Depression Inventory, CAD Canadian, CBA Cognitive Behavioural Approach, CBT Cognitive Behavioural Therapy, EPDS Edinburgh Postnatal Depression Scale, EQ-5D EuroQol-5 dimensions, ICER Incremental cost-effectiveness ratio, NCCMH National Collaborating Centre for Mental Health, NHS National Health Service, NZ New Zealand, OR Odds ratio, PBDU Parent and baby day unit, PHQ Patient Health Questionnaire, PSS Personal Social Services, QALY Quality-adjusted-life-year, RCT Randomised Controlled Trial, RPC Routine primary care, SD Standard deviation, SF-6D Short Form- 6 dimensions, SROI Social return on investment, WTP Willingness-to-pay