Costs and cost-effectiveness of a mental health intervention for war-affected young persons: decision analysis based on a randomized controlled trial.
BACKGROUND
One billion children live in war-affected regions of the world. We conducted the first cost-effectiveness analysis of an intervention for war-affected youth in sub-Saharan Africa, as well as a broader cost analysis.


METHODS
The Youth Readiness Intervention (YRI) is a behavioural treatment for reducing functional impairment associated with psychological distress among war-affected young persons. A randomized controlled trial was conducted in Freetown, Sierra Leone, from July 2012 to July 2013. Participants (n = 436, aged 15-24) were randomized to YRI (n = 222) or care as usual (n = 214). Functional impairment was indexed by the World Health Organization Disability Assessment Scale; scores were converted to quality-adjusted life years (QALYs). An 'ingredients approach' estimated financial and economic costs, assuming a societal perspective. Incremental cost-effectiveness ratios (ICERs) were also expressed in terms of gains across dimensions of mental health and schooling. Secondary analyses explored whether intervention effects were largest among those worst-off (upper quartile) at baseline.


RESULTS
Retention at 6-month follow-up was 85% (n = 371). The estimated economic cost of the intervention was $104 per participant. Functional impairment was lower among YRI recipients, compared with controls, following the intervention but not at 6-month follow-up, and yielded an ICER of $7260 per QALY gained. At 8-month follow-up, teachers' interviews indicated that YRI recipients observed higher school enrolment [P < 0.001, odds ratio (OR) 8.9], denoting a cost of $431 per additional school year gained, as well as better school attendance (P = 0.007, OR 34.9) and performance (P = 0.03, effect size = -1.31). Secondary analyses indicated that the intervention was cost-effective among those worst-off at baseline, yielding an ICER of $3564 per QALY gained.


CONCLUSIONS
The YRI is not cost-effective at a willingness-to-pay threshold of three times average gross domestic product per capita. However, results indicate that the YRI translated into a range of benefits, such as improved school enrolment, not captured by cost-effectiveness analysis. We also outline areas for modification to improve cost-effectiveness in future trials.


BACKGROUND
clinicaltrials.gov Identifier: RPCGA-YRI-21003.
Department of Global Health and Population, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, 02115 MA, USA, Research Center on Children and Global Adversity, FXB Center for Health and Human Rights, Harvard University, Boston, MA, USA and rmcbain@hsph.harvard.edu.
Ryan K
RK
McBain
Department of Global Health and Population, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, 02115 MA, USA.
Carmel
C
Salhi
Research Center on Children and Global Adversity, FXB Center for Health and Human Rights, Harvard University, Boston, MA, USA and.
Katrina
K
Hann
Department of Global Health and Population, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, 02115 MA, USA.
Joshua A
JA
Salomon
Department of Health Policy and Management, Harvard School of Public Health, 617 Huntington Avenue, 7th, Boston, 02115 MA, USA.
Jane J
JJ
Kim
Department of Global Health and Population, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, 02115 MA, USA, Research Center on Children and Global Adversity, FXB Center for Health and Human Rights, Harvard University, Boston, MA, USA and.
Theresa S
TS
Betancourt
D000293:Adolescent; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000191:economics; D011615:Psychotherapy, Group / Q000191:economics* / Q000379:methods; D012807:Sierra Leone; D013315:Stress, Psychological / Q000209:etiology* / Q000628:therapy; D016896:Treatment Outcome; D014857:Warfare; D055815:Young Adult
Cost-effectiveness analysis; disability; mental health; school; sub-Saharan Africa; war