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Cost-effectiveness of early intervention in psychosis: systematic review

  • David Aceituno (a1), Norha Vera (a2), A. Matthew Prina (a3) and Paul McCrone (a4)

Abstract

Background

Early intervention in psychosis (EIP) has been developed as an approach to improve the prognosis of people with psychotic disorders and it has been claimed to be a more efficient model of care. However, the evidence is not definitive and doubts have spread regard to the economic outcomes of EIP services amid the usually restricted mental health budget.

Aims

We aimed to review the cost-effectiveness evidence of EIP services worldwide.

Method

We systematically reviewed the economic literature about EIP following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines. Studies were selected according to previously stated criteria and analysed with standardised critical appraisal tools for trial-based economic evaluations and modelling studies.

Results

A total of 16 studies were selected after applying the eligibility criteria. Most of them were economic evaluations alongside clinical trials. The overall evidence was consistent in the cost-effectiveness of EIP compared with standard care for first episode of psychosis and the Clinical High Risk for Psychosis paradigm. Such evidence was replicated among different health systems, but mainly in high-income countries. The methodological quality of such evidence, however, was moderate and heterogeneity was significant across the studies.

Conclusions

There is consistent evidence that the implementation of EIP services might be a cost-effective alternative across different health systems. Such evidence, nevertheless, derives from heterogeneous and sometimes methodologically flawed studies, reducing the certainty of such statement. More efforts must be done to rigorously assess the value of this intervention, before expanding it among systems where mental health budgets are more constrained.

Declaration of interest

None.

Copyright

Corresponding author

Correspondence: David Aceituno, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK. Email: david.aceituno_farias@kcl.ac.uk

References

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Cost-effectiveness of early intervention in psychosis: systematic review

  • David Aceituno (a1), Norha Vera (a2), A. Matthew Prina (a3) and Paul McCrone (a4)
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eLetters

Unsystematic review shows neither that early intervention in psychosis is cost-effective, nor cost-minimising

Andrew Amos, Associate lecturer, James Cook University
17 June 2019

Aceituno’s systematic review of economic evaluations of early intervention in psychosis (EIP)1 is an example of the use of spin to misrepresent advantages of EIP, a topic reviewed elsewhere2. Although it refers to standard protocols for systematic reviews, it doesn’t critically analyse the collected articles, leading to wildly optimistic conclusions.

I provide several examples, noting my earlier review which critically analysed the papers extant at the time.3 Aceituno reports a cost-effectiveness study based on CBT to prevent transition to psychosis as a positive study, without reference to the fact that the current consensus is that it is not possible to prevent transition to psychosis.4 If a treatment is not effective, it cannot be cost-effective.

The first paragraph of Aceituno’s discussion concludes: “Investing in EIP could, as the best-case scenario, save money, and is at least a more cost-effective alternative than treatment as usual.” As it reviewed cost-effectiveness articles, the article did not provide evidence on whether EIP saves money. Indeed, the review excluded one study explicitly for its cost-minimisation approach, the relevant type of study for assessing whether an intervention can save money.

While Aceituno notes significant methodological limitations in this literature, it doesn’t analyse the fact that 11 of 14 studies demonstrated “Selective reporting (reporting bias)”, according to the Cochrane Risk of bias tool. Alongside the comment: “…more rigorous trials have failed to demonstrate clinical or functional differences with standard care…” this lack of critical interest in evidence of systematic misreporting suggests that Aceituno et al have not actually scrutinised the literature, but only followed protocol.

In addition to ignoring evidence of systematic bias, the failure to identify limitations of specific articles should convince readers of the value of this review. For example, using service records, Tsiachristas identified all patients with psychosis in several regions of England, then compared treatment costs of patients managed in EIP units with those of patients in non-EIP units.5 As there was no matching on duration of illness or treatment, essentially this study compared the costs of treating patients in the first few years of treatment (EIP) to costs of treating patients with established, chronic illness. Given Aceituno doesn’t mention this extreme confound, it seems fair to wonder what level of methodological compromise would have been enough to conclude that the literature cannot be relied upon.

References

1. Aceituno D, Vera N, Prina M, McCrone P. Cost-effectiveness of early intervention in psychosis: systematic review. Br J Psych 2019; online before print

2. Amos A. A review of spin and bias use in the Early Intervention in Psychosis literature. Prim Care Companion CNS Disord 2014; 16(1): 10.4088/PCC.13r01586

3. Amos A. Assessing the cost of early intervention in psychosis: A systematic review. Aus NZ J Psych 2012; 46(8):719-734.

4. Fusar-Poli P, McGorry PD, Kane JM. Improving outcomes of first-episode psychosis: an overview. World Psychiatry 2017; 16:251-265.

5. Tsiachristas A, Thomas T, Leal J, Lennox BR. Economic impact of early intervention in psychosis services: results from a longitudinal retrospective controlled study in England. BMJ Open 2016; 6:e012611.doi:10.1136/bmjopen-2016-012611
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Conflict of interest: None declared

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