Preventing panic disorder: cost-effectiveness analysis alongside a pragmatic randomised trial.
BACKGROUND
Panic disorder affects many people, is associated with a formidable disease burden, and imposes costs on society. The annual influx of new cases of panic disorder is substantial. From the public health perspective it may therefore be a sound policy to reduce the influx of new cases, to maintain the quality of life in many people, and to avoid the economic costs associated with the full-blown disorder. For this purpose, prevention is needed. Here we present the first economic evaluation of such an intervention.


METHODS
Randomised trial of 117 people with panic disorder symptoms not meeting the diagnostic criteria of DSM-IV panic disorder. The interventions were time-limited cognitive-behavioural therapy v care-as-usual. The central clinical endpoint was DSM-IV panic disorder-free survival over 3 months. Costs were calculated from the societal perspective. Using the bootstrap method, incremental cost-effectiveness ratios were obtained, placed in 95% confidence intervals, projected on the cost-effectiveness plane, and presented as acceptability curves.


RESULTS
The median incremental cost-effectiveness ratio is euro6,198 (95% CI 2,435 - 60,731) per PD-free survival gained, which has a likelihood of 75.2% of being more acceptable from a cost-effectiveness point of view than care-as-usual when a willingness-to-pay ceiling is assumed of euro10,000 per PD-free survival. The most significant cost driver was therapists' time. A sensitivity analysis indicated that cost-effectiveness improves when the number of therapist hours is reduced.


CONCLUSIONS
This is the first economic evaluation alongside a prevention trial in panic disorder. The small sample (n = 117) and the short time horizon of 3 months preclude firm conclusions, but our findings suggest that the intervention may be acceptable from a cost-effectiveness point of view, especially when therapist involvement can be kept minimal. Nevertheless, our results must await replication in a larger trial with longer follow-up times before we can confidently recommend implementation of the intervention on a broad scale. In the light of our findings and given the burden of panic disorder, such a new trial is well worth the effort.
Smit
Filip
F
Centre of Prevention and Early Intervention, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, the Netherlands.|Institute of Extra-Mural Medicine, VU University Medical Centre, Amsterdam, the Netherlands.
Willemse
Godelief
G
Centre of Prevention and Early Intervention, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, the Netherlands.
Meulenbeek
Peter
P
Department of Research and Brief Intervention, GGNet (community mental health centre), Warnsveld, the Netherlands.
Koopmanschap
Marc
M
Institute of Medical Technology Assessment, Erasmus University Medical Centre, Rotterdam, the Netherlands.
van Balkom
Anton
A
Department of Psychiatry and EMGO Institute, VU University Medical Centre, Amsterdam, the Netherlands.
Spinhoven
Philip
P
Department of Psychiatry, Leiden University Medical Centre, Leiden, the Netherlands.
Cuijpers
Pim
P
Department of Clinical Psychology and EMGO Institute, VU University Medical Centre, Amsterdam, the Netherlands.