Intended for healthcare professionals

Rapid response to:

General Practice

A randomised controlled trial and economic evaluation of a referrals facilitator between primary care and the voluntary sector

BMJ 2000; 320 doi: (Published 12 February 2000) Cite this as: BMJ 2000;320:419

Rapid Response:

The economic consequences of treating psychosocial disorders

Patients presenting with psychosocial disorders in primary care
create a management dilemma for the physician. With only limited time, the
consultation is often dominated by the need to rule out serious illness
and initiate medical treatment if needed. Follow-up appointments also
suffer from limited time, and consequently voluntary organisations are
often seen as an important source of more intensive support. However, the
paper by Grant et al.1 has highlighted the importance of considering the
economic implications of referring patients to services within the
voluntary sector. These charitable services have limited funds and we need
to ensure that their work is maximally effective.

Untreated psychiatric disorder has significant social and economic
consequences for society and the family2-4, and subsyndromal depressive
symptoms have been shown to be associated with functional impairment5. In
Grant et al.'s study, those in the voluntary service arm showed
significantly greater improvements in anxiety and ability to carry out
everyday activities, although the mean cost was greater than in the usual
general practitioner care arm. This cost differential of £20 over four
months was small compared to the costs of specialist referral, although
major depressive disorder was not effected by the intervention. It is
therefore possible that the increased cost of the intervention was offset
by beneficial economic effects.

Similar difficulties in drawing conclusions from economic analyses
can be seen in other studies. Although a particular benefit may be seen it
may not be translatable into everyday practice. For example, in the
treatment of depression in primary care, tricyclic antidepressants may be
a cost-effective alternative to selective serotonin reuptake inhibitors
given equal efficacy rates in clinical trials and lower acquisition costs
for the tricyclics6;7. However, compared to tricyclics, the selective
serotonin reuptake inhibitors have fewer side-effects, are better
tolerated, and are less toxic in overdose8. These differences may explain
patterns of use seen in the community. In the UK, tricyclics are
prescribed in doses that are lower than the recommended minimums, and
patients tend not to stay on the medication for the recommended period9-
11. Thus, the equal efficacy rates found in clinical trials may not
translate into equal effectiveness in clinical practice.

Reference List

1. Grant C, Goodenough T, Harvey I, Hine C. A randomised controlled
trial and economic evaluation of a referrals facilitator between primary
care and the voluntary sector. BMJ 2000;320:419-23.

2. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The Economic
Burden of Depression in 1990. J Clin Psychiatry 1993;54:405-18.

3. Haddad PM. Depression: counting the costs. Psych Bul. 1994;1994
Jan; vol 18 no 1; 25-28:-28.

4. Rice DP,.Miller LS. The Economic Burden of Affective Disorders.
Br J Psychiatry 1995;166 suppl 27:34-42.

5. Judd LL, Paulus MP, Wells KB, Rapaport MH. Socioeconomic burden
of subsyndromal depressive symptoms and major depression in a sample of
the general population. Am J Psychiatry 1996;153:1411-7.

6. Hotopf M, Lewis G, Normand C. Are selective serotonin reuptake
inhibitors a cost-effective alternative to tricyclics? Br J Psychiatry

7. Song F, Freemantle N, Sheldon TA. Selective serotonin reuptake
inhibitors: meta-analysis of efficacy and acceptibility. BMJ 1994;306:683-

8. British Association for Psychopharmacology. Guidelines for
treating depressive illness with antidepressants. J Psychopharm 1993;7:19-

9. Donoghue JM, Tylee A, Wildgust H. Cross-sectional database
analysis of antidepressant perscribing in general practice in the United
Kingdom. BMJ 1996;313:811-2.

10. Donoghue JM,.Tylee A. The treatment of depression: prescribing
patterns of antidepressants in primary care in the UK. Br J Psychiatry

11. MacDonald TM, McMahon AD, Reid AC, et al. Antidepressant drug
use in primary care: a record linkage study in Tayside, Scotland. BMJ

Competing interests: No competing interests

12 February 2000
Andrew Thornett
Clinical Research Fellow
Department of Psychiatry, University of Southampton, SO14 0YG