Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: Cost effectiveness
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7273.1389 (Published 02 December 2000) Cite this as: BMJ 2000;321:1389
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Editor – In her response to my letter(1) with regards to the article
by Bower et al(2), Byford(3) explains very satisfactory why in economic
evaluations opportunity and average cost respectively should and can be
used. Byford explains this very well: “economic (or opportunity) costs do
not necessarily relate to the price that you pay for a service but to the
benefits which are lost by directing resources to one service rather than
another”.
What then, from a local health service perspective, are the
opportunity costs and benefits?
For Oxfordshire the opportunity cost is 300,000 pound that has been
committed towards additional provision of non-directive counselling and
psychological therapies. This money can now not be spent on assertive
community treatment or any other form of proven intervention in mental
health or elsewhere. The benefits will probably be very much in line with
the findings of Bower’s research, and the opportunity benefit will be, as
Byford stated, in freed up primary and secondary care time. However, given
the intangible opportunity cost and benefits, Bower’s study adds very
little to help Oxfordshire to establish if this has been a cost-effective
investment.
Therefore, in my view, Bower’s conclusions remain over simplistic and
not helpful. A fuller discussion, including Byford’s further explanations,
might have given health services the information to make their own
judgement over the possible cost-effectiveness of investing in non-
directive counselling and cognitive-behavioural therapy. In line with
this, I would have recommended the following conclusion for Bower’s
article:
In conclusion, non-directive counselling and cognitive behavioural
therapy have shown to be as effective as usual general practitioner care
for patients with depression. If health services want to establish the
cost effectiveness of investing in these services, they will have to take
into account the opportunity benefits and costs of providing these
therapies. Within the NHS these benefits will include the freeing up of GP
time and the ability of mental health services to concentrate on Serious
Mental Ill patients. This will enable both primary care and secondary
mental healthcare services to achieve important targets within the NHS
Plan(4) and the National Service Framework for Mental Health(5). However,
local health systems will have to weigh these benefits against the costs
of investing in these services, as this may mean that they will not be
able to invest in other, possibly more effective interventions. For a
local health service, the balance will depend on the services that are
already provided and can only be judged locally.
(1) Chapel H. Health service perspective should not be lost. British
Medical Journal Electronic letter to the Editor 13 December. 2000.
(2) Bower P, Byford S, Sibbald B, Ward E, King M, Lloyd M et al.
Randomised controlled trial of non-directive counselling, cognitive-
behaviour therapy, and usual general practitioner care for patients with
depression. II: Cost effectiveness. BMJ 2000; 321(7273):1389-1392.
(3) Byford S. Re: Health service perspective should not be lost.
British Medical Journal Electronic letter to the Editor 12 January. 2001.
(4) Secretary of State for Health. The NHS Plan; A plan for
investment A plan for reform. 2000. Norwich, HMSO.
(5) Department of Health. National Service Framework for Mental
Health; Modern Standards & Service Models. 1999. London, Department
of Health.
Competing interests: No competing interests
Response to electronic letter by Hendrik Chapel (13 December 2000)
Editor - Chapel (1) raises the issue of average versus marginal
costing in economic evaluations, arguing that the use of average costs in
our cost-effectiveness analysis of psychological therapies for patients
with depression (2) may overstate the true cost-effectiveness of these
interventions. He argues that our results may be relevant to health
services that employ fee-for-service reimbursement, but not for systems
dominated by capitation payments. Whilst we accept the concerns raised, we
would respond with two points. First, economic (or opportunity) costs do
not necessarily relate to the price you pay for a service but to the
benefits which are lost by directing resources to one service rather than
another (3). Economic savings come in the form of freed resources (e.g. GP
or consultant time), rather than monetary expenditures. Thus it is the
opportunity to direct these freed resources elsewhere that is of economic
importance and not the impact on capitation or block contract payments,
which as Chapel points out may be limited. The aim of economics is not to
save money, but to get more benefit from the money (or resources)
available.
Secondly, the predominance of average costs in health economic
evaluations results from the difficulties of implementing marginal costing
in practice (3). Marginal costs are not directly observable and a marginal
costing exercise in this trial would require detailed local information on
the spare capacity and flexibility of all 24 general practices and many
wards and specialities within the hospitals that the trial participants
attended. Such information would be extremely difficult to collate with
any accuracy and would require a significant increase in trial resources.
Since it is widely believed that short-run average costs are an adequate
approximation for long-run marginal costs (4), it is doubtful if the
information gained would have been worth the additional data collection
burden. Furthermore, the more sophisticated and locally specific the
costing process becomes, the less generalisable the results, creating a
trade-off between accuracy and relevance to the wider health service.
We acknowledge Chapel's reference to the broader rationing issues
involved in resource allocation and the need to justify expenditure across
a wider spectrum of interventions. We would argue, however, that this was
not the intended focus of this trial. The question we wished first to
address was the relative cost-effectiveness of the three interventions.
The broader implications are undoubtedly of importance but as Chapel
points out, the utility approach in mental health has its difficulties.
Although the EQ-5D measure of health related quality of life was included
in this trial, the measure was found to be relatively insensitive to the
changes in mental health status picked up by the Beck Depression Inventory
(BDI), the primary outcome measure in the trial. The BDI is a valid and
reliable measure of depression (5) and the trial was powered to detect
differences in the BDI, not the EQ-5D. The confidence we could have in the
results of a cost-utility analysis would, therefore, be limited. To carry
out an adequate cost-utility analysis in the mental health field, more
appropriate and sensitive utility measures are needed which capture the
full range of effects that mental health interventions may have on the
quality of a person's life.
We agree with the need for longer-term follow-up in trials of this
kind, given the often chronic and recurring nature of mental health
problems. However, the results of this trial seem to suggest a relatively
short-term intervention impact, given the trend towards equivalence of
outcomes after the intervention ceased.
1. Chapel H. Health service perspective should not be lost.
Electronic letter to the Editor. BMJ 13 December 2000
2. Bower P, Byford S, Sibbald B, Ward E, King M, Lloyd M, Gabbay M.
Randomised controlled trial of non-directive counselling, cognitive-
behaviour therapy, and usual general practitioner care for patients with
depression. II: Cost effectiveness. BMJ 2000; 321: 1389-1392
3. Drummond MF, O'Brien B, Stoddart GL, Torrance GW. Methods for the
economic evaluation of health care programmes. Oxford: Oxford University
Press, 1997.
4. Allen C, Beecham J. Costing services: ideals and realities. In A.
Netten & J. Beecham (eds), Costing community care: theory and
practice. Aldershot: Ashgate Publishing Ltd, 1993
5. Beck A, Steer R. Beck Depression Inventory: manual. San Antonio:
Psychological Corporation, 1987.
Competing interests: No competing interests
Dear Editor
I would like to know more about "usual GP care". Only a few months
ago I had a letter from a service user with depression (I will not call
her a patient, since she was not even afforded the luxury of a
diagnosis)whose GP had said "you will just have to face the fact that you
are never going to be one of life's little sunbeams". Perhaps she would
have been better off with a chihuahua?
Whilst this study does look beyond cost to user and staff choice and
availability (roll on the 1000 new "Psychoangels" announced in the NHS
Plan?, I cannot see it as particularly powerful or ground-breaking. I
thought we already knew that CBT and counselling were equally efficacious
and what about the person offering the intervention - their motivation and
belief in the therapy, for example?
Isn't one of the problems with applying RCT 'mentality' to complex
human systems that it is simply like trying to sieve flour though a
container whose holes are too big really to do justice to the subject?
Surely, longitudinal tracking naturalistic studies would yield far more of
the quality information we need.
We need to know what works, not what doesn't. On the basis of this
study, if commissioning services, I would maintain my waiting lists and
allow 'time' to deal with those whose condition is going to resolve
spontaneously anyway. I believe there is a high DNA rate for many
psychology services that are not practice-based?
Perhaps we should tease all those psychologists out of their 'sets'
and get them seeing some patients in primary care settings, get away from
all this 'boxed-in thinking and concentrate on issues such as fitness for
purpose, rather than traditional job titles?
Dr Chris Manning
Co-Chair PriMHE
www.primhe.org
Competing interests: No competing interests
Editor – Bower et al take in their cost-effectiveness analysis a
societal point of view but it is also important to consider the health
services point of view(1). Bower’s conclusions may be of direct relevance
for the health services in countries where primary and secondary services
are reimbursed for each individual consultation (as in many countries that
operate a private and/or insurance based health service), but that is not
the practice within the NHS. Within the NHS, GPs receive a capitation
payment for the number of patients on their books, and most psychiatric
services will be reimbursed through block-contracts, the implication being
that the introduction of non-directive counselling and cognitive-behaviour
therapy does not result in direct savings in GP and psychiatric services.
In economic terms, from a NHS point of view, Bower et al should have used
marginal costs for GP and psychiatric services rather then average cost,
in which case these psychological therapies might not be as cost-effective
as suggested.
However, this does not mean that we should not invest in these
therapies, only that the question is more complex than Bower makes it
appear. The question becomes basically a rationing decision: how much
should the NHS invest in non-directive counselling and cognitive-behaviour
therapy? As Richard Smith in his editorial on NICE in the same edition
states, this is not a technical but an ethical judgement(2). Economics can
help with this question, but then it needs to look at cost-utility rather
then cost-effectiveness, eg it should look at how much people become
better over how much time, as expressed in Quality Adjusted Life Years
(QALY), and at what cost. Unfortunately the utility approach in mental
health is fraught with problems(3). How can we establish in a valid way
the utility or well being of people with depression, especially if we want
to compare it with the well being of people with physical problems? The
accompanying article by Ward et al highlights this for although they
report a significant difference in the depression score at 4 months, they
acknowledge that they cannot say what the clinical importance of this
finding is(4). Additionally, the authors do not acknowledge that
psychological therapies may give people the coping mechanism to deal with
outside pressures that could otherwise cause a recurrence of the illness,
a benefit that might well extend far beyond the one year of this study.
Finally, Singer et al describe some of the domains and factors that
can be involved in priority setting and the complexity of rationing
decisions (5). The conclusion has to be that the greater availability of
Cost Utility information in other clinical areas as opposed to mental
health should not stop us from investment in mental health.
Reference List
(1) Bower P, Byford S, Sibbald B, Ward E, King M, Lloyd M et al.
Randomised controlled trial of non-directive counselling, cognitive-
behaviour therapy, and usual general practitioner care for patients with
depression. II: Cost effectiveness. BMJ 2000; 321(7273):1389-1392.
(2) Smith R. The failings of NICE. BMJ 2000; 321(7273):1363-1364.
(3) Mangalore R. The utility approach to valuing health states
in schizophrenia. Mental Health Research Review 2000;(7):11-15.
(4) Ward E, King M, Lloyd M, Bower P, Sibbald B, Farrelly S et al.
Randomised controlled trial of non-directive counselling, cognitive-
behaviour therapy, and usual general practitioner care for patients with
depression. I: Clinical effectiveness. BMJ 2000; 321(7273):1383-1388.
(5) Singer PA, Martin DK, Giacomini M, Purdy L. Priority setting for
new technologies in medicine: qualitative case study. BMJ 2000;
321(7272):1316-1318.
Competing interests: No competing interests
Re: Health service perspective should not be lost
Being in the U.S., I find the differences in health systems as they
relate to decisions about allocating resources very interesting. My
comments refer to the amount of time patients are depressed.
The length of time a patient was relatively more depressed in the
study by Bower, Ward and associates was dependent on the service he or she
received. Those who received psychological therapies seemed to have their
suffering relieved more quickly.
There is data on the Beck Depression Inventory that relates to the
clinical significance of the outcomes in this study. A BDI score of 13
represents two standard deviations above the mean of a non-distressed
group and thus represents a reasonable threshold for a clinically
significant outcome(1).
In Bower, Ward and associates' study, the BDI means at 4 months for
the psychological therapies were 12.7 (cognitive-behavioural) and 11.5
(non-directive), whereas the BDI mean for the Usual GP condition was 17.2.
At 12 months, all three BDI means were below a 13-point cut-off (range =
9.1 to 11.1). The study design did not provide data on how long it took
the Usual GP patients to reach the 13-point threshold. Even if it took
them half of the additional 8 months, that seems to be a nontrivial amount
of depressed living. Of course, that is just one person's opinion.
I think this study is important and I realize that one cannot address
everything in one study. However, I think the authors missed an
opportunity to address the clinical significance of their findings. In
particular, it surprised me when they focused only on the 12-month
equivalence of outcomes in their closing recommendations:
"...commissioners of services are in a position to decide on services
based on factors other than outcomes and costs, such as staff and patient
preferences or staff availability"(Bower et al., p. 1392). I wonder if it
wouldn't be worthwhile addressing the amount of time that patients are
relatively more depressed when making recommendations about allocating
resources.
Reference List
(1) Ogles B, Lambert M, Masters K. Assessing outcome in clinical
practice. London: Allyn and Bacon, 1996.
Competing interests: No competing interests