Cost-effectiveness of a stepped care program to prevent depression among primary care patients with diabetes mellitus type 2 and/or coronary heart disease and subthreshold depression in comparison with usual care

S. E.M. van Dijk, A. D. Pols, M. C. Adriaanse, H. W.J. van Marwijk, M. W. van Tulder, J. E. Bosmans*

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review

Abstract

Background: Patients with diabetes mellitus type 2 (DM2) and/or coronary heart disease (CHD) are at high risk to develop major depression. Preventing incident major depression may be an important tool in reducing the personal and societal burden of depression. The aim of the current study was to assess the cost-effectiveness of a stepped care program to prevent major depression (Step-Dep) in diabetes mellitus type 2 and/or coronary heart disease patients with subthreshold depression in comparison with usual care. Methods: An economic evaluation with 12 months follow-up was conducted alongside a pragmatic cluster-randomized controlled trial from a societal perspective. Participants received care as usual (n = 140) or Step-Dep (n = 96) which consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to a general practitioner. Primary outcomes were quality-adjusted life years (QALYs) and cumulative incidence of major depression. Costs were measured every 3 months. Missing data was imputed using multiple imputation. Uncertainty around cost-effectiveness outcomes was estimated using bootstrapping and presented in cost-effectiveness planes and acceptability curves. Results: There were no significant differences in QALYs or depression incidence between treatment groups. Secondary care costs (mean difference €1644, 95% CI €344; €3370) and informal care costs (mean difference €1930, 95% CI €528; €4089) were significantly higher in the Step-Dep group than in the usual care group. The difference in total societal costs (€1001, 95% CI €-3975; €6409) was not statistically significant. The probability of the Step-Dep intervention being cost-effective was low, with a maximum of 0.41 at a ceiling ratio of €30,000 per QALY gained and 0.32 at a ceiling ratio of €0 per prevented case of major depression. Conclusions: The Step-Dep intervention is not cost-effective compared to usual care in a population of patients with DM2/CHD and subthreshold depression. Therefore, widespread implementation cannot be recommended. Trial registration: The trial was registered in the Netherlands Trial Register (NTR3715).

Original languageEnglish
Article number402
JournalBMC Psychiatry
Volume21
Issue number1
DOIs
Publication statusPublished - Dec 2021

Bibliographical note

Funding Information:
This study was funded by ZonMw, the Netherlands Organization for Health Research and Development (project number 80–82310-97- 12110). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Funding Information:
The authors would like to thank Anna Jansen, Lennart van der Zwaan, Timo Velzeboer, Marleen Reuser, Wendy Kerstens, Jet Bessem, and Walter van Raaij for their contribution in the data collection for this study. We also would like to thank all the participating general practices and the research networks of general practitioners (ANH, THOON and LEON) for their participation and collaboration in the implementation and execution of the study. Furthermore, this study has been possible thanks to all Step-Dep participants; Michiel de Boer, our independent statistician who performed the randomization; Petra Elders who contributed in the design of the study and the recruitment of general practices in the Amsterdam region; and Hanna Joosten, who helped us design the search strategy in the electronic patient record system of the general practices. This research was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration Kent, Surrey, Sussex. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Funding Information:
The authors would like to thank Anna Jansen, Lennart van der Zwaan, Timo Velzeboer, Marleen Reuser, Wendy Kerstens, Jet Bessem, and Walter van Raaij for their contribution in the data collection for this study. We also would like to thank all the participating general practices and the research networks of general practitioners (ANH, THOON and LEON) for their participation and collaboration in the implementation and execution of the study. Furthermore, this study has been possible thanks to all Step-Dep participants; Michiel de Boer, our independent statistician who performed the randomization; Petra Elders who contributed in the design of the study and the recruitment of general practices in the Amsterdam region; and Hanna Joosten, who helped us design the search strategy in the electronic patient record system of the general practices. This research was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration Kent, Surrey, Sussex. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Publisher Copyright:
© 2021, The Author(s).

Copyright:
Copyright 2021 Elsevier B.V., All rights reserved.

Keywords

  • Cardiovascular disease
  • Cost-effectiveness analysis
  • Depression
  • Diabetes mellitus type 2
  • Prevention
  • Randomized controlled trial

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