Economic evaluations of psychological treatments for common mental disorders in low- and middle-income countries: protocol for a systematic review

Figures & data

Table 1. Main types of full economic evaluations*

Type of evaluation	Measurement/ valuation of costs in both alternatives	Identification of consequences	Measurement/valuation of consequences	Explanatory Notes	Policy Applications
Cost effectiveness analysis (CEA)	Monetary units	Single effect of interest, common to both alternatives, but achieved to different degrees.	Natural units (E.g. depression free days (DFDs), change in depression symptom severity, points of blood pressure reduction, etc.)	Provides useful evidence for comparing costs and outcomes for similar treatments using the same clinical outcomes. For example comparing CBT vs B.A as psychotherapeutic treatment for depression, outcome measure depression symptom severity measured using the Patient Health Questionnaire (PHQ-9) in Sun et al. (2021) [34].	Informs resource allocation within mental health budget for similar treatments that are evaluated using the same measure of outcome. Decision making tool: ICER [35]
Cost-utility analysis (CUA)	Monetary units	Single or multiple effects, not necessarily common to both alternatives.	Healthy years (typically measured as quality adjusted life-years (QALYs))	A form of CEA where outcomes are presented as multi-attribute outcomes such as disability adjusted life years (DALYs) and quality adjusted life years (QALYs). QALYs for example consider contributions of interventions to quality of life and length of life thus assisting with global budgetary decisions around how to best allocate health resources to maximize population health, All types of interventions for different conditions can be comparable due to the generic outcome measure. E.g. Sun et al. (2021) [34]	Informs resource allocation across health programs within national health budgets. Decision making tool: ICER and cost-effectiveness threshold [36]
Cost-benefit analysis (CBA)	Monetary units	Single or multiple effects not necessarily common to both alternatives	Monetary units	Ideologically appealing due to the potential to assign a monetary value to the many benefits of mental health treatments experienced across different sectors of society e.g. increased productivity in the workplace, reduced burden on social welfare, reductions in recidivism. However CBAs are difficult to conduct and generalize due to the complexity associated with monetizing benefits and determining the scope of these benefits. e.g. Iijima et al. (2013) [37] & Layard et al. (2007) [38]	Informs resource allocation across multi-sectoral budgets. Decision making tool: net benefits, cost benefit ratio (CBR), benefit cost ratio, return on investment (ROI) [39,40]

*Full economic evaluations compare costs and outcomes across at least 2 competing interventions

Adapted from Drummond et al. (2015) [32]

Table 2. Key economic evaluation definitions [52–56]

Term	Definition
Perspective	The viewpoint or approach taken in costing. A health system or provider perspective includes costs incurred by the provider (which could include a health care or other provider). A patient perspective considers patient, household and societal impacts not born by the provider, such as opportunity costs to patients, lost income by caregivers and productivity losses. A societal perspective includes both provider and patient perspectives.
Time horizon	The time frame over which costs and outcomes associated with an intervention are assessed.
Incremental Cost-Effectiveness Ratio (ICER)	ICER is the ratio of incremental costs to incremental outcomes, with incremental costs as the numerator and incremental outcomes as the denominator. In decision making an intervention with a lower ICER is generally preferred to one with a higher ICER as it is an indication of a lower additional cost per unit of gain.

Table 3. Inclusion and exclusion criteria applied

Parameter	Include	Exclude
Economic Evaluation	Cost-Effectiveness Analysis Cost-Utility Analysis Cost-Consequence Analysis Cost-Benefit Analysis	Cost Analysis Cost-of-illness Budget-Impact Analysis
Design	Quantitative economic evaluation studies Cross sectional or longitudinal primary data collected from trial, non-trial, and quasi-experimental (non-randomised studies) Article reporting economic evaluation only or reporting economic evaluation results as part of an effectiveness trial manuscript Published in peer reviewed journals only	Qualitative studies/study protocols Modelled studies based entirely on secondary data Reviews/ short notes/editorial notes/opinion pieces/commentaries Conference abstracts/ book chapters/dissertations/grey literature
Participants/population	Patients with CMDs* only or with CMDs plus co-morbidities Studies where CMDs are identified using screening instruments and formal diagnoses	Studies that do not report results for CMD conditions separately from other conditions
Intervention(s) and exposure(s)	Psychological treatments for CMDs Psychological treatment as the primary therapy used in conjunction with pharmacotherapy as adjunctive treatment	Treatments that focus primarily or exclusively on the provision of pharmacotherapy only
Comparator(s) control	Full economic evaluation studies where comparators are stated. Examples of comparators may include: No intervention/Standard of care/Treatment as usual/Another intervention.	Studies reporting only costs or only outcomes or costs and outcomes of only one option without a comparator
Outcome	Studies reporting economic evaluation outcomes including natural/clinical and/or multi-attribute outcomes such as QALYs and DALYs	Studies reporting screening or prevention as the outcome rather than treatment related outcomes
Region	Low and middle income countries as defined by the World Bank as at June 2019	High income countries
Dates	Published before 30 June 2021	Published after June 2021
Language	Results presented in the English language	Results presented partly or fully in languages other than English

* CMD operational definition: depressive disorders, anxiety disorders and substance use disorders

Table 4. List of databases to be searched

Bibliographic Databases to be searched
PubMed (including Medline)	✓
EbscoHost (APA-PsycINFO, EconLit, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Africa-Wide Information)	✓
Scopus (including EMBASE)	✓
Web of Science	✓
Cochrane Library (Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL)	✓
Cost-Effectiveness Analysis (CEA) Registry	✓
Centre for Reviews and Dissemination (CRD) (NHS Economic Evaluation Database (NHS EED))	✓

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