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Effectiveness and cost-effectiveness of indicated preventive interventions for depression in adolescents: An application of health economics methods
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Social medicine/CHAP.ORCID iD: 0000-0002-5323-5626
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Description
Abstract [en]

Unipolar depressive disorders are commonly encountered conditions in clinical practice with about 25% reporting their first episode during adolescence. Longitudinal studies show adolescent depression to be associated with an increased risk of mental illness in adulthood, healthcare usage, poor educational outcomes, unemployment, and dependency on welfare recipiency. Therefore, adolescent depression contributes a high disease burden and impinges a considerable financial strain on society’s limited resources.

Several preventive interventions have been developed to prevent adolescent depression. Of these interventions, group-based cognitive behavioural therapy (GB-CBT) indicated preventive interventions for depression are well studied and accepted. However, evaluations of their effectiveness and cost effectiveness have yielded conflicting and incomplete results mainly due to methodological limitations.

Therefore, the overarching aim of this thesis was to investigate the effectiveness and cost-effectiveness of GB-CBT indicated preventive interventions for depression in children and adolescents, and estimate the additional healthcare costs and welfare burden in early to mid-adulthood associated with adolescent depression.

In study I, GB-CBT indicated preventive interventions for depression in children and adolescents were protective against developing a depressive disorder and also reduced depressive symptoms. The intervention relative effect was noted to decay over time. Study II revealed that adolescent depression was associated with considerable increased healthcare consumption in mid-adulthood compared to the non-depressed peers at a population level. This finding was more pronounced in females with persistent depressive disorder (PDD). Study III showed adolescent depression to be associated with all the forms of social transfer payments (welfare) especially in individuals with PDD and those with early comorbid psychopathologies.

Study IV demonstrated that GB-CBT indicated preventive interventions for adolescent depression are not only effective but also have the potential to be cost-effective compared to leaving adolescents with subsyndromal depression unattended.

Findings from studies II and III, emphasized the large financial burden to society in terms of additional healthcare costs and welfare expenditure associated with adolescent depression. Whereas, study I and IV bring forward the message that it is possible to change the course of subsyndromal depression by offering GB-CBT indicated preventive interventions to adolescents with subsyndromal depression. Such an initiative was not only cost-effective compared to not intervening, but also largely cost-saving. Therefore, GB-CBT indicated preventive interventions could be used as part of a stepped care program linking into more specialized care services. The results of this thesis will be useful in decision-making concerning the resource allocation related to adoption and implementation of such preventive measures.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2020. , p. 84
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1640
Keywords [en]
Health economics; adolescent depression; indicated prevention; direct costs; Markov models; welfare burden
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-404547ISBN: 978-91-513-0879-1 (print)OAI: oai:DiVA.org:uu-404547DiVA, id: diva2:1395472
Public defence
2020-04-16, Bertil Hammersalen, Blåsenhus, von Kraemers allé 1, Uppsala., 09:00 (English)
Opponent
Supervisors
Available from: 2020-03-25 Created: 2020-02-22 Last updated: 2020-03-25
List of papers
1. Indicated preventive interventions for depression in children and adolescents: A meta-analysis and meta-regression
Open this publication in new window or tab >>Indicated preventive interventions for depression in children and adolescents: A meta-analysis and meta-regression
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2019 (English)In: Preventive Medicine, ISSN 0091-7435, E-ISSN 1096-0260, Vol. 118, p. 7-15Article, review/survey (Refereed) Published
Abstract [en]

Depression contributes about 2% to the global burden of disease. A first onset of depressive disorder or subsyndromal depressive symptoms is common in adolescence, indicating that early prevention is a priority. However, trials of preventive interventions for depression in youths show conflicting results. This systematic review and meta-analysis investigated the effectiveness of group-based cognitive behavioral therapy (GB-CBT) as a preventive intervention targeting subsyndromal depression in children and adolescents. In addition, the impact of different covariates (type of comparator and use of booster sessions) was assessed. Relevant articles were identified from previous systematic reviews, and supplemented with an electronic search spanning from 01/09/2014 to 28/02/2018. The retrieved articles were assessed for eligibility and risk of bias. Relevant data were extracted. Intervention effectiveness was pooled using a random-effects model and the impact of covariates assessed using meta-regression. 38 eligible articles (34 trials) were obtained. The analysis showed GB-CBT to significantly reduce the incidence (relative risk 0.43, 95% CI 0.21-0.87) and symptoms (Cohen's d -0.22, 95% CI -0.32 to -0.11) of depression at post-test compared to all controls. Comparisons with passive comparators suggested that the effect decayed over time. However, compared to active controls, a significant intervention effect was evident only after 12 month or more. Our results suggest that the preventive effect of GB-CBT wears off, but still lasts longer than the effect of active comparators. Only a few studies included booster sessions, precluding firm conclusions. Future studies should clarify to what extent maintenance strategies can prolong the preventive effect of GB-CBT.

Keywords
Depression, Dysthymia, Cognitive-behavioral therapy, Meta-analysis, Meta-regression, Indicated prevention interventions
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-375899 (URN)10.1016/j.ypmed.2018.09.021 (DOI)000454933300002 ()30287331 (PubMedID)
Funder
Swedish Research Council, 2014-10092Forte, Swedish Research Council for Health, Working Life and WelfareSwedish Research Council FormasVINNOVA
Available from: 2019-02-04 Created: 2019-02-04 Last updated: 2020-02-22Bibliographically approved
2. Depressive disorders in adolescence, recurrence in early adulthood, and healthcare usage in mid-adulthood: A longitudinal cost-of-illness study
Open this publication in new window or tab >>Depressive disorders in adolescence, recurrence in early adulthood, and healthcare usage in mid-adulthood: A longitudinal cost-of-illness study
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2019 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 258, p. 33-41Article in journal (Refereed) Published
Abstract [en]

Background: Depression in adolescence is associated with increased healthcare consumption in adulthood, but prior research has not recognized the heterogeneity of depressive disorders. This paper investigated the additional healthcare usage and related costs in mid-adulthood for individuals with adolescent depression, and examined the mediating role of subsequent depression in early adulthood.

Methods: This study was based on the Uppsala Longitudinal Adolescent Depression Study, initiated in Sweden in the early 1990s. Depressive disorders were assessed in adolescence (age 16-17) and early adulthood (age 19-30). Healthcare usage and related costs in mid-adulthood (age 31-40) were estimated using nationwide population-based registries. Participants with specific subtypes of adolescent depression (n = 306) were compared with matched non-depressed peers (n = 213).

Results: Women with persistent depressive disorder (PDD) in adolescence utilized significantly more healthcare resources in mid-adulthood. The association was not limited to psychiatric care, and remained after adjustment for individual and parental characteristics. The total additional annual cost for a single age group of females with a history of PDD at a population level was estimated at 3.10 million USD. Depression recurrence in early adulthood mediated the added costs for psychiatric care, but not for somatic care.

Limitations: Primary health care data were not available, presumably resulting in an underestimation of the true healthcare consumption. Estimates for males had limited precision due to a relatively small male proportion.

Conclusions: On a population level, the additional healthcare costs incurred in mid-adulthood in females with a history of adolescent PDD are considerable. Early treatment and prevention should be prioritized.

Place, publisher, year, edition, pages
ELSEVIER, 2019
Keywords
Adolescence, Depression, Direct costs, Adulthood, Psychiatric healthcare, Non-psychiatric healthcare
National Category
Psychiatry Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-393715 (URN)10.1016/j.jad.2019.07.077 (DOI)000482176400004 ()31382102 (PubMedID)
Funder
Swedish Research Council, 2014-10092Forte, Swedish Research Council for Health, Working Life and WelfareSwedish Research Council FormasVinnova
Available from: 2019-09-30 Created: 2019-09-30 Last updated: 2020-02-22Bibliographically approved
3. Adolescent depression, early psychiatric comorbidities, and adult welfare burden: A 25-year longitudinal cohort study
Open this publication in new window or tab >>Adolescent depression, early psychiatric comorbidities, and adult welfare burden: A 25-year longitudinal cohort study
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(English)Manuscript (preprint) (Other academic)
Keywords
Adolescence; adulthood; depression; comorbidity; social transfer payments; welfare benefits; financial burden; longitudinal study; epidemiology.
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-404546 (URN)
Available from: 2020-02-22 Created: 2020-02-22 Last updated: 2020-02-28
4. Cost-effectiveness of an indicated preventive intervention for depression in adolescents: a model to support decision making
Open this publication in new window or tab >>Cost-effectiveness of an indicated preventive intervention for depression in adolescents: a model to support decision making
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(English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517Article in journal (Refereed) Submitted
Keywords
Adolescence, Depression, Direct costs, Indirect costs, markov model, and sensitivity analysis.
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-404545 (URN)
Available from: 2020-02-22 Created: 2020-02-22 Last updated: 2020-02-22

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