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Cost-effectiveness of PoNDER health visitor training for mothers at lower risk of depression: findings on prevention of postnatal depression from a cluster-randomised controlled trial

  • Catherine Henderson (a1), Simon Dixon (a2), Annette Bauer (a1), Martin Knapp (a1), C. Jane Morrell (a3), Pauline Slade (a4), Stephen J. Walters (a2) and Traolach Brugha (a5)...

Abstract

Background

There is evidence for the cost-effectiveness of health visitor (HV) training to assess postnatal depression (PND) and deliver psychological approaches to women at risk of depression. Whether this approach is cost-effective for lower-risk women is unknown. There is a need to know the cost of HV-delivered universal provision, and how much it might cost to improve health-related quality of life for postnatal women. A sub-study of a cluster-randomised controlled trial in the former Trent region (England) previously investigated the effectiveness of PoNDER HV training in mothers at lower risk of PND. We conducted a parallel cost-effectiveness analysis at 6-months postnatal for all mothers with lower-risk status attributed to an Edinburgh Postnatal Depression Scale (EPDS) score <12 at 6-weeks postnatal.

Methods

Intervention HVs were trained in assessment and cognitive behavioural or person-centred psychological support techniques to prevent depression. Outcomes examined: quality-adjusted life-year (QALY) gains over the period between 6 weeks and 6 months derived from SF-6D (from SF-36); risk-of-depression at 6 months (dichotomising 6-month EPDS scores into lower risk (<12) and at-risk (⩾12).

Results

In lower-risk women, 1474 intervention (63 clusters) and 767 control participants (37 clusters) had valid 6-week and 6-month EPDS scores. Costs and outcomes data were available for 1459 participants. 6-month adjusted costs were £82 lower in intervention than control groups, with 0.002 additional QALY gained. The probability of cost-effectiveness at £20 000 was very high (99%).

Conclusions

PoNDER HV training was highly cost-effective in preventing symptoms of PND in a population of lower-risk women and cost-reducing over 6 months.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.

Corresponding author

Author for correspondence: Catherine Henderson, E-mail: c.henderson@lse.ac.uk

References

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Adams, G, Gilliford, M, Ukoumunne, O, Eldridge, S, Chinn, S and Campbell, M (2004) Patterns of intra-cluster correlation from primary care research to inform study design and analysis. Journal of Clinical Epidemiology 57, 785794.
Appleby, L, Warner, R, Whitton, A and Faragher, B (1997) A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. British Medical Journal Publishing Group BMJ (Clinical research ed.) 314, 932936.
Bauer, A, Knapp, M and Adelaja, B (2016 a) Best Practice for Perinatal Mental Health Care: The Economic Case. London: Personal Social Services Research Unit.
Bauer, A, Knapp, M and Parsonage, M (2016 b) Lifetime costs of perinatal anxiety and depression. Journal of Affective Disorders 192, 8390.
Bijl, RV, De Graaf, R, Hiripi, E, Kessler, RC, Kohn, R, Offord, DR, Ustun, TB, Vicente, B, Vollebergh, WAM, Walters, EE and Wittchen, HU (2003) The prevalence of treated and untreated mental disorders in five countries. Health Affairs 22, 122133.
Brazier, J, Roberts, J and Deverill, M (2002) The estimation of a preference-based measure of health from the SF-36. Journal of Health Economics 21, 271292.
British Medical Association and Royal Pharmaceutical Society (2011) British National Formulary (BNF). London: BMA and RPS.
Brugha, TS, Morrell, CJ, Slade, P and Walters, SJ (2011) Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care. Psychological Medicine 41, 739748.
Brugha, TS, Sharp, HM, Cooper, S-A, Weisender, C, Britto, D, Shinkwin, R, Sherrif, T and Kirwan, PH (1998) The Leicester 500 Project. Social support and the development of postnatal depressive symptoms, a prospective cohort survey. Psychological Medicine 28, 6379.
Buuren, S van and Groothuis-Oudshoorn, K (2011) Mice: multivariate imputation by chained equations in R. Journal of Statistical Software 45, 167.
Cohen, J (1988) Statistical Power Analysis for the Behavioral Sciences, 2nd Edn. Hillsdale, NJ: Lawrence Earlbaum Associates.
Cowley, S, Caan, W, Dowling, S and Weir, H (2007) What do health visitors do? A national survey of activities and service organisation. Public Health 121, 869879.
Cowley, S, Whittaker, K, Grigulis, A, Malone, M, Donetto, S, Wood, H, Morrow, E and Maben, J (2013) Why Health Visiting? A Review of the Literature About key Health Visitor Interventions, Processes and Outcomes for Children and Families. London: National Nursing Research Unit, King's College London. National Nursing Research Unit, King's College London.
Cox, JL, Holden, JM and Sagovsky, R (1987) Detection of postnatal depression: development of the 10-item Edinburgh postnatal depression scale. British Journal of Psychiatry 150, 782786.
Curtis, L and Burns, A (2015) Unit Costs of Health and Social Care 2015. Canterbury: Personal Social Services Research Unit (PSSRU): University of Kent.
Davis, WW (2001) Design and Analysis of Cluster Randomization Trials in Health Research. Journal of the American Statistical Association vol 96. London: Arnold.
Department of Health (2000) NHS Trust Financial Returns. Leeds: Department of Health.
Department of Health (2005) NHS reference Costs 2004. Leeds: Department of Health.
Department of Health (2015) Transfer of 0–5 children's public health commissioning to Local Authorities.
Dolman, C, Jones, I and Howard, LM (2013) Pre-conception to parenting: a systematic review and meta-synthesis of the qualitative literature on motherhood for women with severe mental illness. Archives of Women's Mental Health 16, 173196.
Ford, E, Shakespeare, J, Elias, F and Ayers, S (2017) Recognition and management of perinatal depression and anxiety by general practitioners: a systematic review. Family Practice 34, 1119.
Gavin, NI, Gaynes, BN, Lohr, KN, Meltzer-Brody, S, Gartlehner, G and Swinson, T (2005) Perinatal depression. Obstetrics & Gynecology 106, 10711083.
Gavin, NI, Meltzer-Brody, S, Glover, V and Gaynes, BN (2015) Is population-based identification of perinatal depression and anxiety desirable? In Milgrom J and Gemmill AW (eds), Identifying Perinatal Depression and Anxiety: Evidence-Based Practice in Screening, Psychosocial Assessment, and Management. Chichester, UK: John Wiley & Sons, Ltd, pp. 1131.
Glick, HA, Doshi, JA, Sonnad, SS and Polsky, D (2007) Economic Evaluation in Clinical Trials. OUP Catalogue. Oxford, New York: Oxford University Press.
Gomes, M, Díaz-Ordaz, K, Grieve, R and Kenward, MG (2013) Multiple imputation methods for handling missing data in cost-effectiveness analyses that use data from hierarchical studies: an application to cluster randomized trials. Medical Decision Making 33, 10511063.
Gomes, M, Grieve, R, Nixon, R and Edmunds, WJ (2012 a). Statistical methods for cost-effectiveness analyses that use data from cluster randomized trials: a systematic review and checklist for critical appraisal. Medical Decision Making 32, 209220.
Gomes, M, Grieve, R, Nixon, R, Ng, ESW, Carpenter, J and Thompson, SG (2012 b). Methods for covariate adjustment in cost-effectiveness analysis that use cluster randomised trials. Health Economics (United Kingdom) 21, 11011118.
Hansard (2004 a). Written answers, Monday 23 May 2005.
Hansard (2004 b). Written answers, Tuesday 19 October 2004.
Health Education England (2016) Explore roles: Health visitor.
Henderson, S, Byrne, DG and Duncan-Jones, P (1981) Neurosis and the Social Environment. Sydney, London: Academic Press.
Herrin, J (2012) CLTEST: Stata modules for performing cluster-adjusted chi-square and t tests. Statistical Software Components.
Hewitt, CE and Gilbody, SM (2009) Is it clinically and cost effective to screen for postnatal depression: a systematic review of controlled clinical trials and economic evidence. BJOG: An International Journal of Obstetrics and Gynaecology 116, 10191027.
Holden, JM, Sagovsky, R and Cox, JL (1989) Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. British Medical Journal Publishing Group BMJ (Clinical research ed.) 298, 223226.
Jorm, AF, Patten, SB, Brugha, TS and Mojtabai, R (2017) Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry 16, 9099.
Klar, N (2015) A Practical Guide to Cluster Randomised Trials in Health Services Research, vol. 3406. Chichester: Wiley.
Kohn, R, Saxena, S, Levav, I and Saraceno, B (2004) The treatment gap in mental health care. Bulletin of the World Health Organization 82, 858866.
Manca, A, Hawkins, N and Sculpher, MJ (2005 a). Estimating mean QALYs in trial-based cost-effectiveness analysis: the importance of controlling for baseline utility. Health Economics 14, 487496.
Manca, A, Rice, N, Sculpher, MJ and Briggs, AH (2005 b). Assessing generlisability by location in trial-based cost-effectiveness analysis: the use of multilevel models. Health Economics 14, 471485.
Mantopoulos, T, Mitchell, PM, Welton, NJ, McManus, R and Andronis, L (2016) Choice of statistical model for cost-effectiveness analysis and covariate adjustment: empirical application of prominent models and assessment of their results. European Journal of Health Economics 17, 927938.
Megnin-Viggars, O, Symington, I, Howard, LM and Pilling, S (2015) Experience of care for mental health problems in the antenatal or postnatal period for women in the UK: a systematic review and meta-synthesis of qualitative research. Archives of Women's Mental Health 18, 745759.
Milgrom, J and Gemmill, AW (2014) Screening for perinatal depression. Best Practice and Research Clinical Obstetrics and Gynaecology 28, 1323.
Morrell, CJ, Ricketts, T, Tudor, K, Williams, C, Curran, J and Barkham, M (2011) Training health visitors in cognitive behavioural and person-centred approaches for depression in postnatal women as part of a cluster randomised trial and economic evaluation in primary care: the PoNDER trial. Primary Health Care Research & Development 12, 1120.
Morrell, CJ, Slade, P, Warner, R, Paley, G, Dixon, S, Walters, SJ, Brugha, T, Barkham, M, Parry, GJ and Nicholl, J (2009 a). Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care. BMJ 338, a3045.
Morrell, CJ, Sutcliffe, P, Booth, A, Stevens, J, Scope, A, Stevenson, M, Harvey, R, Bessey, A, Cantrell, A, Dennis, CL, Ren, S, Ragonesi, M, Barkham, M, Churchill, D, Henshaw, C, Newstead, J, Slade, P, Spiby, H and Stewart-Brown, S (2016) A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression. Health Technology Assessment 20, 1414.
Morrell, CJ, Warner, R, Slade, P, Dixon, S, Walters, S, Paley, G and Brugha, T (2009 b). Psychological interventions for postnatal depression: cluster randomised trial and economic evaluation. The PoNDER trial. Health Technology Assessment 13, iii–iv, xi–xiii, 1153.
National Institute for Clinical Excellence (2004) Guide to The Methods of Technology Appraisal. London: National Institute for Clinical Excellence.
National Institute for Health and Care Excellence (2013) Guide to The Methods of Technology Appraisal 2013. London: National Institute for Health and Care Excellence.
National Institute for Health and Clinical Excellence (2008) Guide to The Methods of Technology Appraisal. London: National Institute for Health and Clinical Excellence.
Netten, A and Curtis, L (2004) Unit Costs of Health and Social Care 2004. Canterbury: Personal Social Services Research Unit (PSSRU): University of Kent.
O'Connor, E, Rossom, RC, Henninger, M, Groom, HC and Burda, BU (2016) Primary care screening for and treatment of depression in pregnant and postpartum women. American Medical Association JAMA 315, 388.
Panageas, KS, Schrag, D, Russell Localio, A, Venkatraman, ES and Begg, CB (2007) Properties of analysis methods that account for clustering in volume–outcome studies when the primary predictor is cluster size. Statistics in Medicine 26, 20172035.
Petrou, S, Morrell, J and Spiby, H (2009) Assessing the empirical validity of alternative multi-attribute utility measures in the maternity context. Health and Quality of Life Outcomes 7, 40.
Prady, SL, Pickett, KE, Petherick, ES, Gilbody, S, Croudace, T, Mason, D, Sheldon, TA and Wright, J (2016) Evaluation of ethnic disparities in detection of depression and anxiety in primary care during the maternal period: combined analysis of routine and cohort data. British Journal of Psychiatry 208, 453461.
Ramsey, SD, Willke, RJ, Glick, H, Reed, SD, Augustovski, F, Jonsson, B, Briggs, A and Sullivan, SD (2015) Cost-effectiveness analysis alongside clinical trials II—an ISPOR good research practices task force report. Value in Health 18, 161172.
R Core Team (2016) R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing.
Reay, R, Matthey, S, Ellwood, D and Scott, M (2011) Long-term outcomes of participants in a perinatal depression early detection program. Journal of Affective Disorders 129, 94103.
Robitzsch, A, Grund, S and Henke, T (2016) Some additional multiple imputation functions, especially for mice (Version 2.1-0).
Rubin, DB (1987) Multiple Imputation for Nonresponse in Surveys. New York, Chichester: Wiley.
Slade, P, Morrell, CJ, Rigby, A, Slade, P, Morrell, CJ, Rigby, A and Ricci, K (2010) Postnatal women’ s experiences of management of depressive symptoms: a qualitative study. The British Journal of General Practice: the Journal of the Royal College of General Practitioners 60, 440448.
Songoygard, KM, Stafne, SN, Evensen, KA, Salvesen, KA, Vik, T and Morkved, S (2012) Does exercise during pregnancy prevent postnatal depression? A randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica 91, 6267.
StataCorp (2015) Stata Statistical Software: Release 14 SE. College Station, Texas: StataCorp LP.
Thomas, CM and Morris, S (2003) Cost of depression among adults in England in 2000. British Journal of Psychiatry 183, 514519.
Ukoumunne, OC (2002) A comparison of confidence interval methods for the intraclass correlation coefficient in cluster randomized trials. Statistics in Medicine 21, 37573774.

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