Health–economic benefits of treating trauma in psychosis

Figures & data

Figure 1. Cost-utility of QALY gain in main analysis (EM) after bootstrapping (n = 2500) comparing EMDR and PE to WL: ICUR planes and acceptability curves.

Abbreviations: CAU = care as usual; EMDR = eye movement desensitization and reprocessing; ICUR = incremental cost-utility ratio; PE = prolonged exposure; QALY = Quality Adjusted Life Year; Q1 = Quadrant 1 (more effective, more expensive); Q2 = Quadrant 2 (the inferior quadrant: less effective, more expensive); Q3 = Quadrant 3 (less effective, less expensive); Q4 = Quadrant 4 (the dominant quadrant: more effective, less expensive); WL = waiting list.

Table 1. Baseline characteristics of the intention-to-treat sample for the three conditions with costs under expectation maximization imputation (N = 155).

	EMDR (n = 55)	PE (n = 53)	WL (n = 47)	Total sample (n = 155)
Demographic characteristics
Age (years), mean (SD)	40.4 (11.3)	42.6 (10.3)	40.3 (9.7)	41.2 (10.5)
Female gender (%)	30 (54.5)	30 (56.6)	24 (51.1)	84 (54.2)
Dutch cultural background (%)	34 (61.8)	36 (67.9)	27 (57.4)	97 (62.6)
Lower education^a (%)	30 (54.5)	23 (43.4)	26 (55.3)	79 (51.0)
Unemployed (%)	51 (92.7)	45 (84.9)	41 (87.2)	137 (88.4)
Living alone or in sheltered housing (%)	36 (65.4)	34 (64.2)	30 (63.8)	100 (64.5)
Clinical characteristics
Psychosis, lifetime diagnosis MINI-Plus (%)
Schizophrenia	34 (61.8)	31 (58.5)	30 (63.8)	95 (61.3)
Schizoaffective disorder	15 (27.3)	17 (32.1)	13 (27.7)	45 (29.0)
Remaining psychotic disorders	3 (5.5)	1 (1.9)	1 (2.1)	5 (3.2)
Mood disorders with psychotic features	3 (5.4)	4 (7.6)	3 (6.4)	10 (6.4)
Chlorpromazine drug dose equivalents^b, mean (SD)	253.2 (250.5)	227.3 (187.9)	250.7 (232.8)	243.6 (224.2)
Psychosis duration in years, mean (SD)	18.2 (11.7)	18.9 (12.8)	15.7 (10.5)	17.7 (11.8)
PTSD, CAPS severity score, mean (SD)	72.1 (17.6)	69.6 (14.9)	68.1 (15.9)	69.9 (16.2)
PTSD duration in years, mean (SD)	21.1 (13.9)	22.8 (13.6)	18.95 (12.9)	21.0 (13.5)
Economic characteristics
Utility, EQ5D, Mean (SD)	0.55 (0.29)	0.46 (0.31)	0.43 (0.29)	0.48 (.30)
Costs, TiC-P, in 2014 Euro per month, Mean € (SD)
Health care^c	689.2 (1005.5)	678.0 (747.2)	1012.6 (1699.8)	783.4 (1195.4)
Outpatient mental health service	262.4 (516.6)	261.0 (427.5)	260.0 (335.6)	–
Inpatient mental health service	142.8 (746.2)	0 (0.0)	57.8 (249.0)	–
Medical non-mental health care	16.4 (41.2)	21.7 (45.5)	14.8 (37.7)	–
Family doctor/GP	16.2 (29.7)	27.4 (36.5)	19.0 (30.6)	–
Alternative healing	0 (0.0)	9.8 (51.1)	1.5 (7.4)	–
Psychopharmacology^a	7.6 (8.9)	8.6 (12.9)	5.2 (5.9)	–
Paramedical care	77.3 (159.8)	141.4 (253.6)	111.6 (257.0)	–
Professional home care	45.6 (116.8)	63.8 (145.9)	43.1 (77.1)	–
Informal care (family, friends)	103.2 (277.3)	120.2 (288.6)	477.2 (1629.7)	–
Out-of-pocket costs (travel)	17.9 (22.2)	24.0 (22.5)	22.2 (21.3)	–
Productivity losses	213.4 (318.5)	323.9 (600.9)	208.5 (315.6)	249.7 (436.1)
Work loss	5.7 (42.2)	34.1 (165.6)	42.9 (203.7)	–
Work cut-back	21.8 (127.8)	118.2 (457.9)	51.4 (178.4)	–
Domestic loss and cut-back	185.9 (292.5)	171.5 (206.1)	114.3 (116.1)	–
Total societal cost	902.6 (1060.8)	1001.9 (905.4)	1221.1 (1717.6)	1033.1 (1252.9)

Abbreviations: CAPS = Clinician-Administered PTSD Scale; EMDR = eye movement desensitization and reprocessing; EQ5D = EuroQol 5D; MINI-Plus = MINI-International Neuropsychiatric Interview-Plus; PE = Prolonged Exposure; PTSD = posttraumatic stress disorder; SD = standard deviation; TiC-P = Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness; WL = Waiting list.

^aLower = primary education or lower general secondary education, as opposed to intermediate to high vocational education or university.

^b100 mg CPZ = 2 mg Haldol; medication prescribed for psychotic disorders and mood disorders with psychotic features.

^cThe cost item of ‘outpatient mental health service’ included visits to psychiatrists, psychologists, nurses and so on. ‘General hospital’ included costs related to somatic care visits. Visits to the ‘family doctor/GP’ were categorized separately. ‘Alternative healing’ included all visits to healthcare workers outside regular care, e.g. paranormal healers. ‘Psychopharmacology’ included all medication plus dispensing costs of non-controlled-for medication. ‘Paramedical care’ included care such as physiotherapy or dietetics. ‘Professional home care’ included all professional household support whereas ‘informal care’ included all support from family and peers. Healthcare-related transportation costs (‘out-of-pocket costs’) included all trips to healthcare services, including parking costs.

Table 2. Results of main analysis and sensitivity analyses.

								ICURs/ICERs in plane quadrants^d, %
		Incremental costs, €		Incremental effects		Mean bootstrapped ICUR/ICER, €		EMDR				PE
		EMDR	PE	EMDR	PE	EMDR	PE	Q1	Q2	Q3	Q4	Q1	Q2	Q3	Q4
Cost-utility analysis QALY gain
main analysis^a, EM	total societal costs	–1574	–422	0.05	0.05	–30061	–8209	1.8	0.0	0.8	97.4	30.1	0.1	0.4	69.4
	health care costs	–1410	–501	0.05	0.05	–26924	–9741	1.1	0.0	0.9	98.0	24.4	0.1	0.3	75.2
sensitivity analyses^a
LOCF	total societal costs	–1533	–996	0.06	0.06	–27157	–15636	5.3	0.0	0.5	94.2	16.4	0.1	0.1	83.4
	health care costs	–1470	–1117	0.06	0.06	–26053	–17536	5.4	0.1	0.5	94.0	12.1	0.0	0.2	87.7
REG	total societal costs	–1079	–594	0.06	0.05	–19254	–11084	5.3	0.0	0.5	94.2	22.0	0.1	0.3	77.6
	health care costs	–906	–728	0.06	0.05	–16166	–13584	7.0	0.0	0.4	92.6	14.3	0.1	0.3	85.3
EM excluding hospital^b	total societal costs	–929	–327	0.05	0.05	–17746	–6348	7.4	0.0	0.4	92.2	31	0.1	0.1	68.8
	health care costs	–765	–405	0.05	0.05	–14608	–7880	8.2	0.1	0.4	91.3	24.8	0.1	0.2	74.9
Cost-effectiveness analysis PTSD Loss of Diagnosis^c
main analysis^a, EM	total societal costs	–1574	–422	0.26	0.22	–6138	–1892	1.1	0.0	0.1	98.8	28.9	0.0	0.3	70.8
	health care costs	–1410	–501	0.26	0.22	–5497	–2245	1.5	0.0	0.0	98.5	23.7	0.1	0.3	75.9
sensitivity analysis^a
LOCF	total societal costs	–1.533	–996	0.28	0.29	–5457	–3469	5.7	0.0	0.0	94.3	16.4	0.0	0.0	83.6
	health care costs	–1.470	–1117	0.28	0.29	–5235	–3891	4.6	0.0	0.0	95.4	10.9	0.0	0.0	89.1
REG	total societal costs	–1079	–594	0.23	0.27	–4711	–2180	5.5	0.0	0.7	93.8	21.0	0.0	0.0	79.0
	health care costs	–906	–728	0.23	0.27	3955	–2672	6.8	0.0	0.6	92.6	11.8	0.0	0.1	88.1
EM excluding hospital^b	total societal costs	–929	–327	0.26	0.22	–3623	–1463	7.8	0.0	0.1	92.1	32.0	0.1	0.4	67.5
	health care costs	–765	–405	0.26	0.22	–2983	–1816	8.6	0.0	0.1	91.3	26.0	0.0	0.3	73.7

Abbreviations: EM = expectation maximization; EMDR = eye movement desensitization and reprocessing; ICER = incremental cost-effectiveness ratio; ICUR = incremental cost-utility ratio; LOCF = last observation carried forward; REG = regression imputation; PE = Prolonged Exposure; QALYs = quality-adjusted life years;

^aThe analysis comprised the following cost categories: included all direct and indirect (travel) medical costs; included experimental session costs but excluded implementation costs of the experimental condition; included costs stemming from lower productivity at work or home over six months.

^bEM excluding hospital = as the main EM analysis, but excluding the variable of costs of psychiatric hospital admissions.

^cLoss of diagnosis indicates the combination of no longer meeting CAPS-PTSD criteria + CAPS-severity score < 45.

^dICER plane quadrant: Q1, Quadrant 1 (more effective, more expensive); Q2, Quadrant 2 (the inferior quadrant: less effective, more expensive); Q3, Quadrant 3 (less effective, less expensive); Q4, Quadrant 4 (the dominant quadrant: more effective, less expensive).

Figure 2. Cost-effectiveness of PTSD loss of diagnosis^a in main analysis (EM) after bootstrapping (n = 2500) comparing EMDR and PE to WL: ICER planes and acceptability curves.

Abbreviations: CAU = care as usual; EMDR = eye movement desensitization and reprocessing; ICER = incremental cost-effectiveness ratio; PE = prolonged exposure; PTSD = posttraumatic stress disorder; QALY = Quality Adjusted Life Year; Q1 = Quadrant 1 (more effective, more expensive); Q2 = Quadrant 2 (the inferior quadrant: less effective, more expensive); Q3 = Quadrant 3 (less effective, less expensive); Q4 = Quadrant 4 (the dominant quadrant: more effective, less expensive).^a ‘PTSD loss of diagnosis’ indicates the combination of no longer meeting CAPS IV-PTSD criteria + CAPS IV-severity score < 45.