Cost effectiveness of internet-based cognitive behaviour therapy and behavioural stress management for severe health anxiety

Erik Hedman, Erik Andersson, Brjánn Ljótsson, Erland Axelsson, Mats Lekander, Erik Hedman, Erik Andersson, Brjánn Ljótsson, Erland Axelsson, Mats Lekander

Abstract

Objectives: Internet-delivered exposure-based cognitive behaviour therapy (ICBT) has been shown to be effective in the treatment of severe health anxiety. The health economic effects of the treatment have, however, been insufficiently studied and no prior study has investigated the effect of ICBT compared with an active psychological treatment. The aim of the present study was to investigate the cost effectiveness of ICBT compared with internet-delivered behavioural stress management (IBSM) for adults with severe health anxiety defined as Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) hypochondriasis. ICBT was hypothesised to be the more cost-effective treatment.

Setting: This was a cost-effectiveness study within the context of a randomised controlled trial conducted in a primary care/university setting. Participants from all of Sweden could apply to participate.

Participants: Self-referred adults (N=158) with a principal diagnosis of DSM-IV hypochondriasis, of whom 151 (96%) provided baseline and post-treatment data.

Interventions: ICBT or IBSM for 12 weeks.

Primary and secondary measures: The primary outcome was the Health Anxiety Inventory. The secondary outcome was the EQ-5D. Other secondary measures were used in the main outcome study but were not relevant for the present health economic analysis.

Results: Both treatments led to significant reductions in gross total costs, costs of healthcare visits, direct non-medical costs and costs of domestic work cutback (p=0.000-0.035). The incremental cost-effectiveness ratio (ICER) indicated that the cost of one additional case of clinically significant improvement in ICBT compared with IBSM was $2214. The cost-utility ICER, that is, the cost of one additional quality-adjusted life year, was estimated to be $10,000.

Conclusions: ICBT is a cost-effective treatment compared with IBSM and treatment costs are offset by societal net cost reductions in a short time. A cost-benefit analysis speaks for ICBT to play an important role in increasing access to effective treatment for severe health anxiety.

Trial registration number: NCT01673035; Results.

Keywords: HEALTH ECONOMICS.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
Cost-effectiveness plane comparing internet-based cognitive behaviour therapy (ICBT) to internet-based behavioural stress management (IBSM).
Figure 2
Figure 2
Cost-effectiveness acceptability curve comparing internet-based cognitive behaviour therapy (ICBT) to internet-based behavioural stress management (IBSM).
Figure 3
Figure 3
Cost-effectiveness utility plane comparing internet-based cognitive behaviour therapy (ICBT) to internet-based behavioural stress management (IBSM).

References

    1. Seivewright H, Salkovskis P, Green J et al. . Prevalence and service implications of health anxiety in genitourinary medicine clinics. Int J STD AIDS 2004;15:519–22. 10.1258/0956462041558122
    1. Fink P, Ørnbol E, Christensen KS. The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health. PLoS ONE 2010;5:e9873 10.1371/journal.pone.0009873
    1. Tyrer P, Cooper S, Crawford M et al. . Prevalence of health anxiety problems in medical clinics. J Psychosom Res 2011;71:392–4. 10.1016/j.jpsychores.2011.07.004
    1. Barsky AJ, Fama JM, Bailey ED et al. . A Prospective 4- to 5-year study of DSM-III-R hypochondriasis. Arch Gen Psychiatry 1998;55:737–44. 10.1001/archpsyc.55.8.737
    1. Abramowitz JS, Braddock AE. Psychological treatment of health anxiety and hypochondriasis: a biopsychological approach. Cambridge, MA: Hogrefe & Huber Publishers, 2008.
    1. Olatunji BO, Kauffman BY, Meltzer S et al. . Cognitive-behavioral therapy for hypochondriasis/health anxiety: a meta-analysis of treatment outcome and moderators. Behav Res Ther 2014;58:65–74. 10.1016/j.brat.2014.05.002
    1. King JT Jr, Tsevat J, Lave JR et al. . Willingness to pay for a quality-adjusted life year: implications for societal health care resource allocation. Med Decis Making 2005;25:667–77. 10.1177/0272989X05282640
    1. Seivewright H, Green J, Salkovskis P et al. . Cognitive-behavioural therapy for health anxiety in a genitourinary medicine clinic: randomised controlled trial. Br J Psychiatry 2008;193:332–7. 10.1192/bjp.bp.108.052936
    1. Tyrer P, Cooper S, Salkovskis P et al. . Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet 2014;383:219–25. 10.1016/S0140-6736(13)61905-4
    1. Hedman E, Andersson G, Andersson E et al. . Internet-based cognitive-behavioural therapy for severe health anxiety: randomised controlled trial. Br J Psychiatry 2011;198:230–6. 10.1192/bjp.bp.110.086843
    1. Hedman E, Axelsson E, Görling A et al. . Internet-delivered exposure-based cognitive-behavioural therapy and behavioural stress management for severe health anxiety: randomised controlled trial. Br J Psychiatry 2014;205:307–14. 10.1192/bjp.bp.113.140913
    1. Hedman E, Ljótsson B, Lindefors N. Cognitive behavior therapy via the internet: a systematic review of applications, clinical efficacy and cost-effectiveness. Expert Rev Pharmacoecon Outcomes Res 2012;12:745–64. 10.1586/erp.12.67
    1. Hedman E, Andersson E, Lindefors N et al. . Cost-effectiveness and long-term effectiveness of internet-based cognitive behaviour therapy for severe health anxiety. Psychol Med 2013;43:363–74. 10.1017/S0033291712001079
    1. Mihalopoulos C, Chatterton ML. Economic evaluations of interventions designed to prevent mental disorders: a systematic review. Early Interv Psychiatry 2015;9:85–92. 10.1111/eip.12156
    1. Saha S, Hoerger TJ, Pignone MP et al. . The art and science of incorporating cost effectiveness into evidence-based recommendations for clinical preventive services. Am J Prev Med 2001;20:36–43. 10.1016/S0749-3797(01)00260-4
    1. Svanborg P, Åsberg M. A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale. Acta Psychiatr Scand 1994;89:21–8. 10.1111/j.1600-0447.1994.tb01480.x
    1. McManus F, Surawy C, Muse K et al. . A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). J Consult Clin Psychol 2012;80:817–28. 10.1037/a0028782
    1. Treanor M. The potential impact of mindfulness on exposure and extinction learning in anxiety disorders. Clin Psychol Rev 2011;31:617–25. 10.1016/j.cpr.2011.02.003
    1. Hedman E, Ljótsson B, Andersson E et al. . Effectiveness and cost offset analysis of group CBT for hypochondriasis delivered in a psychiatric setting: an open trial. Cogn Behav Ther 2010;39:239–50. 10.1080/16506073.2010.496460
    1. Hedman E, Andersson E, Lindefors N et al. . Cost-effectiveness and long-term effectiveness of internet-based cognitive behaviour therapy for severe health anxiety. Psychol Med 2013;43:363–74. 10.1017/S0033291712001079
    1. Clark DM, Salkovskis PM, Hackmann A et al. . Two psychological treatments for hypochondriasis. A randomised controlled trial. Br J Psychiatry 1998;173:218–25.
    1. Ost LG. Applied relaxation: description of a coping technique and review of controlled studies. Behav Res Ther 1987;25:397–409. 10.1016/0005-7967(87)90017-9
    1. Ljótsson B, Hedman E, Andersson E et al. . Internet-delivered exposure-based treatment vs. stress management for irritable bowel syndrome: a randomized trial. Am J Gastroenterol 2011;106:1481–91. 10.1038/ajg.2011.139
    1. Salkovskis PM, Rimes KA, Warwick HM et al. . The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med 2002;32:843–53. 10.1017/S0033291702005822
    1. EuroQol-Group. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 1990;16:199–208. 10.1016/0168-8510(90)90421-9
    1. Rabin R, de Charro F. EQ-SD: a measure of health status from the EuroQol Group. Ann Med 2001;33:337–43. 10.3109/07853890109002087
    1. Hakkaart-van Roijen L, Donker MCH. Manual/iMTA questionnaire for costs associated with psychiatric illness (TIC-P). Institute of Medical Technology Assessment (iMTA) Erasmus University Rotterdam, 2002.
    1. Drummond MF, Sculpher MJ, Torrence GW et al. . Methods for the evaluation of health care programmes. Oxford: Oxford University Press, 2005.
    1. Hedman E, Ljótsson B, Rück C et al. . Internet administration of self-report measures commonly used in research on social anxiety disorder: a psychometric evaluation. Comput Hum Behav 2010;26:736–40. 10.1016/j.chb.2010.01.010
    1. Gueorguieva R, Krystal JH. Move over ANOVA: progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry. Arch Gen Psychiatry 2004;61:310–17. 10.1001/archpsyc.61.3.310
    1. Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991;59:12–19. 10.1037/0022-006X.59.1.12
    1. Efron B, Tibshirani RJ. An introduction to the bootstrap. New York: Chapman & Hall, 1993.
    1. Dolan P. Modeling valuations for EuroQol health states. Med Care 1997;35:1095–108. 10.1097/00005650-199711000-00002
    1. Fenwick E, Byford S. A guide to cost-effectiveness acceptability curves. Br J Psychiatry 2005;187:106–8. 10.1192/bjp.187.2.106
    1. World Health Organization. WHO Commission on Macroeconomics and Health. Macroeconomics and Health: investing in health for economic development. Report of the Commission on Macroeconomics and Health Executive Summary Geneva, 2001.
    1. Statistics Sweden. Total income from employment and business 2013, 2015.
    1. Patel A, Rendu A, Moran P et al. . A comparison of two methods of collecting economic data in primary care. Fam Pract 2005;22:323–7. 10.1093/fampra/cmi027

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다