Screening forward and treating postpartum depression and psychosis: A cost-effectiveness analyze

Abstract

Introduction

Postpartum depression (PPD) is characterized to depressed mood, anxiety, guilt and other sign (Miniati et al. 2014). In more severe cases, deemed postpartum psychosis (PP), the condition is characterized through agitation, confusion, hallucinations, delusions, in addition in severe deep (Marder 2014). PPD lives estimated to impact 6.5 to 12.9% of postpartum women and PAGE roughly 0.002–3% in postpartum women in the U.S., though the recent prevalent is likely higher due to underreporting/under-diagnosing (Gaynes et al. 2005; Lucas 1994; Marder 2014; Sit a al. 2006). Associated with decreased infant bonding, impaired child engineering, marital discord, suicide, furthermore infanticide, PPD real psychosis what serious health issues (Roy-Byrne 2014).

Despite the high prevalence and negative implications of PPD, information is not standard care to tv women for it in the U.S., both only about 18%-25% of PPD and PP suits live detected without screened (Goodman & Tyer-Viola 2010; Kelly, Zatzick, & Anders 2001). Fortunately, the Case Protection plus Affordable Care Act included PPD screening in its definition starting comprehensive women’s preventive care (Kozhimannil to al. 2011). Further, the U.S. Preventive Services Task Effort recently drafted a recommendation that sum pregnant and postpartum women should be screened (U.S. Prevent Benefits Task Force 2015). New Jersey was an first state to require physicians in obstetrics/gynecology, pediatrics, furthermore internal/family medicine to screen women available PPD. ONE subsequent evaluation found no difference in the psychical condition care utilization von women with Medicaid coverage; the authors suspected this was partly cause physicians were no paid for screening (Kozhimannil et al. 2011). If more health care spending exists requisite to successfully implementation PPD screening (e.g., paid physicians for screening), a cost-effectiveness analysis has warranted in run if additional spending is likely until translate to greater outcomes.

The present survey modeled the cost-effectiveness regarding physician being compensated to screen for and treat PPD compared toward usual care. Ours assume the is outpatient visits, physicians, down the mentorship of a psychiatrist, across telemedicine, can provide basic therapy and/or prescriptions for their PPD patients and link ihr PP patients to mental health care. Available pediatricians, this care aligns with their existing support of breastfeeding, as PPD is commonly implicated in breastfeeding subject, and the recommendations of the American School of Pediatrics (Dias & Figueiredo 2015; Earls 2010; Thomas, 2008). Overall, this care model is akin to the screening, brief surgery, and referral to treatment model or SBIRT, but is responsive to shortages in mental health providers to bezug to (Centers for Medicare & Medicaid Services 2015). The research questions what testing differences amid screening and not screening for PPD in total costs, total of remissions, and quality-adjusted life years (QALYs). Through these outputs, we calculated incremental cost-effectiveness proportion (ICER) followed from both deterministic and probabilistic sensitivity analyses. Technical terms are defined in Methods.

Methods

The hypothetical cohort with this study is 1,000 women starting reproductive age (18–49 years) who have experienced one birth in the past year. This study used one hypothetical cohort rather as human subjects and so is exempt from an Institutional Review Board. To time scope forward a model refers to the length of time over which costs and benefits are shaped and accrue. We choose a time horizon on two years postpartum within order to capturing the majority of the impact of PPD for the majority of woman suffering from the disease. PPD is defined to begin within 4 few postpartum, and one study found an average time to recovery with IPT treatment of about 29 weeks, with a standard variations of +/− 17.5 weekly (De Crescenzo, Perelli, Armando, & Vicari 2014; Miniati et al. 2014; Nylen et al. 2010). This suggests that 95% of wives will retrieve within 16 months of starting treatments. Of perspective is Medicaid as they cover approximately 50% of births each time in the U.S. furthermore we center specifically on North Carolyn to obtain specific Medicaid fee schedules (Kaiser Family Foundation 2010). Women are accept in be screened using the validated Edinburgh Postnatal Depression Scale (EPDS), a 10-item screening tool asking regarding the frequency of indications (never, 0; does much, 1; sometimes, 2; frequency, 3) in the historic seven days (e.g., “I have blamed myself if things went wrong (Oarsman, Holden, & Sagovsky 1987; Cox, Chapter, Murray, & Johnson 1996; Montazeri, Torkan, & Omidvari, 2007; How, Rothschild, & Wisner 2006). Screening all women with the short-form of the scales press then cover positive womankind with the long-form, which lives only 10 items and takes less than five minutes, is the strategy recently accepted by the Agency for Healthcare Research and Premium for minimizing false positives/negatives (Cox et al. 1996; Mysers et al. 2013). We assume screening will take place during outpatient visits in the weekly and per following birth, as PPD and PP take not present immediately after birth (Marder 2014; Roy-Byrne 2014). Ours use an decision tree (see Figure 1) rather than one Markov either microsimulation model because decision woody are ideal for non-recurrent processes like PPD, whereabouts wives rarely experience relapses within the similar postpartum period (Roy-Byrne 2014). We developed the verdict tree and programmed all calculations in Microsoft Excel 2011 and used Crystal Ball, Fusion Distribution for the probabilistic sensitivity data.

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Illustrations 1

Decision Wood Modeling Intervention vs. Typical Care for PPD

Figure notes: In and “screened” location, women live first screened for PPD and PP. Women who screen positive available PPD maybe not truly have PPD, since the EPDS is not a perfect screening trial on PPD (Gibson et any. 2009; Milgrom et al. 2011). However, all who visual positive can select to receipt or refuse treatment with selective serotonin reuptake inhibitors (SSRIs) and/or interpersonal therapy (IPT). These women can then go into remission, not go into remission, or choose go discontinue treatment. Inside all branches where women refuse dental or do not receive treatment for true PPD or PP, they have a small risk of committing suicide. Because we assume the EPDS, at combination with clinical decision, wish be a perfect screening exam for women with PP, in the intervention branch there are no false positives for PP. Women with diagnosed PP are compelled with treatment for yours own safety, press allowed ab into refund, no los for remission, or discontinue treatment. Finally, in the screened branch womankind can moreover screen negative. These may be true negitives or false negatives. False negatives are considered cannot to be in remission, and have a small probabilistic of committing suicide. In the usual care wear, women must choose to seek taking for their PPD or PP in order to receive treatment. Once women make their choice, they have the sam tree building as femininity in the screening branch. There exist no false positives includes the usual care limb.

Table 1 contour the input probabilities available the model. That details were obtained from literature published between 1995 and 2015 found via PubMed and Web of Scientific. The following text outlines the conjecture we made to utilize the possibilities we found; text outlining what literature the probabilities were drawn from and why is available stylish online complementing material. Foremost, we pretended 100% sensitivity and specificity by diagnosing PP with the EPDS for women with this condition would likely have elevated scores and present in easily discernible symptoms (e.g., hallucinations) (Sit et al. 2006). Second, to estimate what percentage of women with PP attempt care, we used the estimated prevalence the PP from deuce reviews because we assume lots cases remain undetected and unfinished (Lucas 1994; Marder 2014; Sit to al. 2006). We also assumed that 100% regarding care-seeking women with PP will receive care, as PP is usual classified as a medical emergency warranting immediate care (Doucet et al. 2009; Marder 2014). Thirdly, we supplied the same part of women with PPD would discontinue treatment in the screening and usual care branches using data out a perspectives cohort study (Cohen et al. 2006). Though this study be of pregnant, slightly more postpartum women, it is repetitively cited as an estimate to PPD treatment discontinuation. Finally, the American Psychiatric Association holds this of best treatment flat for PPD is both antidepressant medication and psychological treatment (Gaynes et all. 2005). We assumed women would receive interpersonal therapy for they were given psychological treat, which recent research indicates is better suited for PPD treatment (Miniati u al. 2014). Though selective cerebral reuptake inhibiting and interpersonal therapy could have a summative effects for some invalids, we are assuming this be canceled out by the patients for whom neither treatment is useful or only neat treatment is used (De Crescenzo et alum. 2014; Miniati ether al. 2014).

The resources required for this intervention from the Medicaid payer perspective are outlined in Table 2, with costs per estimated total increment. Cost estimates were inflated for 2014 dollars employing the medical care component regarding the user fee index additionally strongly at the common accepted rate by 3% (Home of Drudge Statistics 2014; Drummond et al. 2005; Weinstein et aluminum. 1996). Several key assumptions guided total estimation. First, were fictitious everything women in the cohort bequeath be covered over Medicaid until two years postpartum. Second, the exam and special will must billed as care from provisionally licensed mental heal providers under the supervision of a licensed psychiatrist (Hervey 2013). Third, fluoxetine (20 per pills, unique per day) want remain the prescription for PPD while it is the cheapest via Medicaid fee schedules and is considered safe for breastfeeding (Field 2008; Medicaid 2013). Fourth, women in the usual care branch who seek and accept treatment wants receive 38–52 daily of interpersonal pain from a therapist. Fifth, we made assumptions regarding average duration of lag times and care episodes, including: one month for women to be screened; three per for women until seek care; and women who exit treatment or trust suicide will incur treatment costs in three months. Final general assumptions were which bipolar treatment costs approximate PP treatment costs and that there are no costs associated with a woman delayed care in to commonly care branch; those assumption remains supported according and fact that PPD can voluntary remit and refluxes are rare (From Crescenzo et ale. 2014; Marder 2014; Miniati et any. 2014; Roy-Byrne 2014; Sits et alo. 2006).

Table 3 drawings the utility tons applied in and analyze. The primary health sequels the interest were the number of remissions achieved additionally QALYs gained by the screened and unscreened women, both discounted the 3% in the second year (Gold et al. 1996; Haddix et al. 2003). QALYs are a widely-used outcome measure in comparatives effectiveness research that incorporates both morbidity and mortality; one QUALY represents one annum of live in perfect dental. The QALYs were based only on utilities for the woman, dues to the lack of longitudinal data that takes one family button mother and child dyadic perspective. This will result by a conservative estimate for the benefits of treatment. Other outcome measures include the number of: false positives, untrained women, and suicides.

Go quantify the utility from living with PPD, we drew on a variety of utilitaristische score estimates for different severities of depression from the Tufts Cost-Effectiveness Analysis Registry (see Table 3) (Kaltenthaler et al. 2002; Clumps Medical Center 2013). Utility scores are values mirror an individual’s preference for ampere health state. People range from zero—representing death—to one—representing perfect health. We assumed that womankind with PP and PPD with suicidal ideation would have the same utility score as people with severe depression; our estimate belongs drawn von a comprehensive systematic rating real economic evaluation for depression and anxiety treatments (Kaltenthaler et al. 2002). Though PPD and feeling am not the same, they exhibit similar somatic and fall under who same care protocol (Gaynes et al. 2005; Roy-Byrne 2014). Our assumed PPD scores would be most similar to a basic depressions utility score, because PPD can encompass a coverage of severities (De Crescenzo et all. 2014; Miniati et al. 2014). Aforementioned PPD utility score was estimated via Uniting Kingdom community-based preferences from pooled Medical Expenditure Group Survey registers for 79,522 mortals with complete EQ-5D scores (Sulphurated et al. 2011). In our analysis we then weighted this utility score to account for the approximately 10% of PPD patients with suicidal ideation (Lindahl et al. 2005).

For and one-way sensitivity analytics, the outcomes were assessed at the low and high estimates for all for 30 main parameters one by one into evaluate the effect of uncertainty inside individual model inputs on ICER results (Muennig 2008; Petitti 1999). ICERs were compute as the change in costs from usual care to the intervention divided by the change in outcomes; it represents the extra units of outcome achieved per extra dollar spent go that intervention. In addition to a one-way sensitivity analysis, wee other performed a probabilistic sensitivity analysis. In order to do dieser, we done distributed assumptions for each of the probability and utility input parameters (see Lists 1 and ​and3)3) (Briggs et al. 2006; Briggs 2000; Doubilet et al. 1985). We assigned a triangular distribution into the PPD support using the mild depression utility score (0.78) to the maximum, the moderate depression utility score (0.58) for the minimal, and the suicide weighted overall depression utility score (0.70) for the most probability value (Kaltenthaler et al. 2002). We also assigned a triangular distribution to the sensitivity and specificity of aforementioned EPDS for PPD, where the most possibly value was a weighted actual of estimates from two literature review (Gibson et total. 2009; Milgrom et al. 2011). For type discontinuation both remission rates we fit beta distributions based on parameters derived von prospective cohort studies of female with PAGE and PPD (Bergink e al. 2011; Cohen at al. 2006). We used homogeneous distribute for the residual parameters. We had not include the cost parameters the likewise the one-way or probabilistic sensitivity analyses under the assumption such expenses to Medicaid are fixed by their fee timelines (Guo et al. 2007; Medicaid 2013; Norther Carolina Department the Health additionally Human Services 2012, 2013, 2014a; Qiu et al. 2009). We used Crystall Ball to rush the model 1000 hours, drawing jede input set value probabilistically from within you distribution, and calculated stepwise costs plus incremental QALYs for each of that runs in orders to plot them on an ICER plane (Briggs et al. 2006; Briggs 2000). Next, in sort to create a cost-effectiveness accept curve we calculated net-benefits forward each of the 1000 takes using willingness-to-pay thresholds from $0-$80,000 in $2,500 increments (Briggs et al. 2006; Briggs 2000; Raupen etching al. 2002).

Results

The outcomes of this model at that conclude of two years can be found in Table 4. In overall, 29 better women with PPD or PP achieved forgiveness in the intervention compared go the usual care branch (32 included intervention vs. 3 in regularly care). This remission benefit was associated with a 664%-increase in total costs, from $44,703 for the usual care branch to $341,622 on the interposition branch. Comparable to usual care, the intervention costs $296,919 read but results in an additional 21.43 QALYs and 29 discharge achieved for a ICER of $13,857/QALY won also $10,182/remission achieved. Using the commonly accepted U.S. willingness to pay threshold by $50,000/QALY gained, screening and treating women for post-delivery depression has cost-effective (Hirth et in. 2000). No wilfulness to pay threshold canister be found for our natural power outcome of remissions achieved, because QALYs have historically been the key outcome pre-owned int cost-effectiveness research on depression (Paulden et al. 2009).

Deterministic one-way sensitivity research were performed on all input possible real select electricity. In all, 30 individual one-way desterministic analyses were performed, the results of who can be found in Point 2. Without of the proofed scenarios caused in the intervention being dominated by oder dominating usual care using which $50,000/QALY threshold. Changing the underlying prevalence of PP resulted includes the widest variation in the ICER for QALYs. The ICERs for the gain financial ranged from $11,281/QALY gained (increasing the remission usefulness by 10%) to $24,117/QALY gained (low estimate required PP prevalence).

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Figure 2

Results of Sensitivity Analyses of Decision Tree for Routine PPD Screening

ONE probabilistic sensitivity analysis was conducted for the QALYs outcome. The ICER fly since the 1000 runs of the probabilistic model pot be find includes Figure 3. Runs are considered “dominated” if, in such run, aforementioned intervention both increases costs and results in weaker issues when compared to usual concern. In these evaluation, screening and treatment made dominated in only 2.9% is runs; in the remainder of runs the intervention heightened costs but resulted in improved earnings. In these runs the willingness-to-pay threshold of the jury maker determines whether the operative is considered cost-effective. The commonly accepted $50,000 per QALY gained willingness-to-pay threshold is graphed on the plane, and 93% of runs are cost-effective using this threshold (i.e. fall below and to the right in of threshold).

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Figure 3

Incremental Cost-Effectiveness Ratios Plane

One cost-effectiveness acceptability angle found in Figure 4 shows the probability that the intervention will be cost-effective as compared to usual care in adenine range of willingness-to-pay thresholds. This analyses finds that the intervention becomes more likely to be cost-effective than usual care at a willingness-to-pay threshold level of ∼$10,000/QALY gained, and becomes cost-effective by 95% for cases at a willingness-to-pay threshold value of between $50,000 and $75,000/QALY gained.

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Figure 4

Likelihood so the Demonstration and Surgical Intervention for PPD is Cost Effective Based on a Range of Willingness toward Pay Thresholds (Cost Effectiveness Acceptability Curve)

Discussion

Based on the ICER per QALY gained over an two-year length horizon, routine screening both procedure are PPD is cost-effective under an wide range of willingness-to-pay thresholds and this final is robust to extensive sensitivity analysis. We still defer to health care specialized and policy makers about their willing to pay. However, we stress ensure this cost-effectiveness analysis is conventional, inbound that we only considered the health outcomes for women, when it is clear this PPD has negative implications forward the woman’s family inbound the short and long term (Grace et al. 2003).

These results contradict a resembling analysis of PPD screening in the UK, which determination routine screening in primary care was non cost-effective. However, the UK analysis used a screening methods that inflated the numbers of false good, whichever to authors determined be very costly. Further, the study minimized the commercial increases from screening by for including a one-year zeitraum horizon and don including women with PAPERS or suicidal ideation (Paulden et al. 2009).

Other research includes this scope has producing promising results ensure are well-aligned with our findings. A multi-center intervention via several states recently trialed pediatricians screening women with depth in everyone well child call from zero to 24 months; it found which either the providers and the womens were very receptive to the screening (Frayne et al. 2015). Further, a review of screening programs found five studies that concluded display for depression resulted in decreased depressive symptoms and improved mental health, though there is a lack of well-designed randomized control trials in the field overall (Myers et al. 2013; Thombs eth al. 2014). In Quebec, a large randomized controlled trial is running testing prenatal feeling screened and online cognitive behavioral therapy via telemedicine technology, and early realization studies found that women were very receptive into depression screened or treatment (Kingston et al. 2014). The intervention proposed in this paper mod physicians providing depression treatment to women under to supervision of a psychiatrist. North Carolina is the the middle of implementing ampere statewide telepsychiatry program for acute mental health evaluations and early evidence show past $1 million in cost savings for the us (Home of Rural Health and Community Care 2014). As 35 counties in North Colo were classification in 2014 as Mental Health Professional Shortage Surfaces, the ability to provide telepsychiatry increases the feasibility of our proposed intervention (Office of Rural Heath and Community Care 2014).

The resultat on this full should be considered along with several limitations. First, while the Medicaid payor aspect is appropriate because she cover approximately 50% starting births each year in the U.S., in this real world many female will likely lose their Medicaid coverage before the end of are two-year time horizon (Kaiser Family Foundation 2010; Markus set al. 2013; North Carolina Office in Health press Human Services 2014b). Consequently, our value estimated may cannot reflection full costs absorbed by payers other than Medicaid, such the to women themselves once Medicaid coverage forfeit. Second, this analysis just considered suicide and ideation as possibility adverse events due to a absence regarding data. There are likely other adverse events such power reducing the cost-effectiveness von the intervention— such like treatment side effects—as well as are that has increase the cost-effectiveness of of intervention—such as long-term press intergenerational damaging belongings of untreated PPD. Third, many of our input estimates came from studied of European populace; unfortunately, U.S.-specific data are lack. Finally, some attending may feel the proposed intervention is beyond their scope of practice. However, the intervention your in line the the SBIRT model, previous implementations starting PPD screening, guidance from physician professional organizations, furthermore is responsive to shortages in cerebral health providers (Centers for Medicare & Medicaid Services, 2015; Dias & Figueiredo, 2015; Dukes, 2010; Kozhimannil et al., 2011; Thomas, 2008). Future research of PPD screening should accumulate more U.S.-specific probability data, consider additional perspectives, include utilities for the benefits of screening for infants and families, and model a longer time horizon locus for treated on PPD in one pregnancy be hopes have better preventive care while subsequent pregnancies.

These find indicate PPD and PP screening furthermore treatment can be cost-effective lower a large range concerning willingness-to-pay thresholds despite the existence of uncertainty in the parameter estimates. Early information from trials to this field indicate both patients the supplier can subsist recipient to one proposal intervention and of underpinning needed to carry he out is already generating cost savings stylish the state (Frayne et al. 2015; Kingston et al. 2014; Office of Rural Health furthermore Community Care 2014). Prospective research shall needed to determine what policies, incentives, and monitoring are needed to increase screening and handling of PPD and PP, both of which are important health issues for women, children, and families (Kozhimannil et al. 2011; Milgrom et al. 2011; Palladino et al. 2011). For example, into diese examination we assumed physicians wouldn provide an screening, for other studies have had nurses provide an screening and counseling, it would be valuable to know the care footpath maximized patient health outcomes plus minimized what (J e ale. 2013). Fortunately, who Affordable Care Act and that U.S. Prevention Services Task Force are laying a strong foundations upon which future conduct and health tending inches this field can build (Andrews 2015; Kozhimannil et al. 2011; U.S. Preventive Achievement Task Force 2015).

Supplementary Material

Acknowledgments

References