Cost-effectiveness of WHO Problem Management Plus for adults with mood and anxiety disorders in a post-conflict area of Pakistan: randomised controlled trial

Abstract

Background With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up. Aims To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au). Method We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores. Results The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262–4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434–820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394–77 399) (US$517), compared with PKR 10 705 (95% CI 7731–15 627) (US$102.93) using a local supervisor. Conclusions The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.

Effectiveness of a brief group behavioral intervention for common mental disorders in Syrian refugees in Jordan: A randomized controlled trial

“…It is noteworthy that despite a brief training of only 8 days for the group facilitators in gPM+, the group sessions resulted in improved mental health; this amount of training is comparable with other evidence-based psychosocial programs [ 56 ] and is an important requisite for scalable interventions. Group-based programs may be more cost-effective than individually administered psychological interventions [ 57 ], and when they can be effectively delivered by nonspecialists, this further increases the likelihood that programs such as gPM+ could be implemented in refugee camps in poorly resourced countries [ 58 ]. Further, group interventions can be more acceptable in collectivist societies, including Syrian refugees [ 36 ].…”

Does health economics research align with the disease burden in the Middle East and North Africa region? A systematic review of economic evaluation studies on public health interventions

“…Geographically, this review identified 18 studies (30%) from Israel [ 25 , 28 – 30 , 36 – 40 , 52 , 54 , 56 , 58 , 65 , 72 , 73 , 80 , 81 ], ten studies (16%) from Iran [ 21 , 26 , 41 , 45 , 46 , 63 , 67 , 68 , 70 , 79 ], and five studies from Egypt [ 33 , 34 , 50 , 61 , 62 ] and Pakistan [ 42 – 44 , 47 , 55 ] (8% each). Further, the researchers obtained three studies from Afghanistan [ 27 , 31 , 76 ], Jordan [ 23 , 32 , 57 ] and Lebanon [ 48 , 49 , 71 ] (5% each) and two studies (3%) from Turkey [ 64 , 69 ].…”

“…$ 141,641 and Int. $ 389,148/QALY gained in the first, second and third rounds of screening program, respectively Mammography screening program is cost effective in 53% of the cases, but ICER/QALY in the second and third rounds of screening are not cost-effective Hamdani et al [ 42 ] Pakistani Pakistani Pakistani NA Government US$ 67 The mean ICER to successfully treat a case of depression using an international supervisor was US$ 517 compared with US$ 102.93 using a local one The Problem Management + is more effective but also more costly Howard et al [ 43 ] Pakistani Pakistani and international NR Afghan None 1–3 GDP/C (US$ 479–1436 in 2015) The additional cost of including indoor residual spraying over five years per case prevented was US$ 39 (50 for Vivax and 182 for Falciparum ). Per DALY averted this was US$ 266 Adding indoor residual spraying is cost-effective Hussain et al [ 44 ] Pakistani NR International International NGO NR Incentive-based active case finding program costs US$ 223 per patient treated and incrementally averted 0.17 DALYs at the cost of US$ 15.74 over 6 months Both screening strategies appear to be cost-effective in an urban Pakistani context Javadinasab et al [ 45 ] Iranian Iranian and international Iranian and international International NR 1–3 GDP/C (US$ 5442–16,326 in 2014) In CUA, compared with no screening, the ICERs/QALY gained were US$ 489 for one screening/lifetime at age 50, US$ 709 for one screening/lifetime at age 55, US$ 1010 for screening every 10 years starting at age 50, US$ 1386 for screening every 10 years starting at age 40, US$ 2310 for screening every 5 years starting at age 50 and US$ 3135 for screening every 5 years starting at the age of 40.…”

Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis

“…PM+ for individuals led to improvements in anxiety, depression, post-traumatic stress disorder (PTSD), psychosocial functioning and self-identified problems 3 months after the intervention 21 23. Although PM+ was more effective in reducing symptoms of common mental disorders, it was also costlier compared with CAU alone 25. PM+ delivered in groups (gPM+) to women in Pakistan was effective in reducing symptoms of anxiety, depression, and self-identified problems, but not for symptoms of PTSD 22.…”