The BRENDA model: integrating psychosocial treatment and pharmacotherapy for the treatment of alcohol use disorders

While the U.S. Food and Drug Administration has approved several medications for the treatment of alcohol-related problems, their use has not gained wide acceptance in the United States. Typically, patients with alcohol use disorders are only referred to psychosocial support (e.g., Alcoholics Anonymous). However, the use of pharmacotherapy may complement psychosocial treatments, as evidence shows that pharmacotherapy can improve treatment outcomes. The effectiveness of pharmacotherapy depends on patient compliance with taking the medication and the context in which the medication is administered. BRENDA is a psychosocial program designed specifically to be used by many types of healthcare providers, including primary care clinicians. Designed to enhance medication and treatment compliance, BRENDA is an ideal approach for use in conjunction with pharmacotherapy. The BRENDA approach has 6 components: 1) a biopsychosocial evaluation; 2) a report of findings from the evaluation given to the patient; 3) empathy; 4) addressing patient needs; 5) providing direct advice; and 6) assessing patient reaction to advice and adjusting the treatment plan as needed. This paper describes these components and discusses how the empirical support for each component is linked to the enhancement of medication compliance and the improvement of treatment outcomes.     

Beyond model programs: evaluation of a countywide system of residential treatment programs

Assessing deinstitutionalization as a social policy requires examining a system of programs rather than single, "model" services. The authors report an evaluation of 19 residential treatment programs in Hennepin County, Minnesota, that provide three different levels of care (intensive, transitional, and supportive) for mentally ill clients. Data on client characteristics, program outcomes, and hospitalization costs were collected in two study periods between 1980 and 1985. The results showed that the programs served three distinct client subpopulations that differed in recidivism, vocational status, discharge setting, and costs according to the type of program. Clients in all programs made substantial gains in community integration, and as a group the programs were cost-effective.     

Cost-effectiveness of systematic depression treatment for high utilizers of general medical care

BACKGROUND: Expanding access to high-quality depression treatment will depend on the balance of incremental benefits and costs. We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care. METHODS: Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years. A 2-step screening process identified patients with current depressive disorders, who were not in active treatment. Eligible patients were randomly assigned to continued usual care (n = 189) or to an organized depression management program (n = 218). The program included patient education, antidepressant pharmacotherapy initiated in primary care (when appropriate), systematic telephone monitoring of adherence and outcomes, and psychiatric consultation as needed. Clinical outcomes (assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months) were converted to measures of "depression-free days." Health services utilization and costs were estimated using health plan-standardized claims. RESULTS: The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months (95% confidence interval [CI], 28.2-67.8 days). Estimated cost increases were $1008 per year (95% CI, $534-$1383) for outpatient health services, $1974 per year for total health services costs (95% CI, $848-$3171), and $2475 for health services plus time-in-treatment costs (95% CI, $880-$4138). Including total health services and time-in-treatment costs, estimated incremental cost per depression-free day was $51.84 (95% CI, $17.37-$108.47). CONCLUSIONS: Among high utilizers of medical care, systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs.     

Coping with dementia: evaluation of four nonpharmacologic interventions

To evaluate nonpharmacologic interventions, caregivers (65 women, 38 men) and their dementia-diagnosed spouses (patients) were randomized to one of four treatment programs (cognitive stimulation, dyadic counseling, dual supportive seminar, and early-stage day care) or to a wait-list control group. Assessments occurred initially and at postintervention (3 months). Patients were evaluated on memory, verbal fluency, and problem-solving ability, and caregivers were assessed on marital interaction, emotional status, and physical health, along with stress, coping, and social support. Caregivers also completed a program evaluation. Repeated measures procedures showed that patients in the cognitive stimulation group demonstrated more improvement over time in cognitive outcomes, and caregivers decreased in depressive symptoms. Early-stage day-care and dual supportive seminar group caregivers reported a decrease in hostility and a decrease in use of negative coping strategies, respectively. Although qualitatively derived benefits differed across groups, similarities in program content reduced the potential for quantitative differentiation among the groups.     

Prophylactic treatment of mood disorders: cost effectiveness analysis comparing lithium and carbamazepine

Economic impact of lithium therapy has seldom been assessed, economic comparisons with alternative mood stabilizers are almost non existent. This economic evaluation of preventive treatment of mood disorders recurrences (whether unipolar or bipolar) compared lithium with carbamazepine, through data from a randomized controlled clinical trial. A retrospective analysis of medical files of index patients is included in this trial, with experts' global ratings. A brief survey checked for representativity of in-patients length of stay. The model compared two cohorts of patients followed-up for two years after prophylactic treatment had begun. Rates of recurrence and direct medical costs related to mood disorders (prophylactic treatment, treatment of recurrences and serious adverse effects) were assessed. Data extrapolation was necessary because of variable lengths of follow-up during the trial and was based on medical review of index patients. Assessment of consumed health care resources were derived from the available database of the clinical trial, when necessary practice guidelines and experts' opinions were added to the model. Costs were valued according to available french unit costs (Vidal, NGAP, and Comptes de la santé). Analysis only included direct costs. An estimate of mean cost of care of 15,404 French francs per year per patient was calculated. The components of health costs show that in-patient costs are the most important part of annual medical costs for mood disorders (70% of the total costs). Prophylactic medication costs accounted for only 6.9% of total costs. Comparison of prophylactic alternatives gave lithium a clinical benefit with 27% fewer recurrences than carbamazepine. Lithium led to an economic benefit of 4,280 French francs per year of treatment for a single patient. Robustness of this finding was assessed through a sensitivity analysis on estimate of length of stay. Total costs of treatment would be equal between lithium and carbamazepine if length of stay in hospital for lithium patients was increased by 51%. According to the cost-effectiveness analysis developed in this study, lithium should stay the "gold standard" of prophylactic treatment of recurrent mood disorders, and has both clinical and economic advantages compared to carbamazepine.     

Stem cell transplantation in multiple sclerosis: safety and ethics

Stem cell therapy is considered a promising strategy aiming at neuronal and glial cell replacement or neuroprotection in neurological diseases affecting the brain and spinal cord. Multiple Sclerosis (MS), characterized by inflammation-induced destruction of the myelin sheath surrounding axons leading to conduction deficits and variability of clinical signs, is not an exception. MS is considered an autoimmune disease and, in the last few years, an intense immunodepletion followed by autologous hematopoietic-stem-cell transplant (HSCT) is being assessed as potential therapeutical strategy for severe patients unresponsive to the immunomodulatory and immunosuppressive treatment. Partially supported by evidence in animal models and by anecdotal reports on the beneficial effects on MS patients with concomitant malignant diseases, HSCT programs for MS have been initiated worldwide and follow-up data are accumulating. A Consensus Meeting has been held in Milano (1998) providing a document that defined criteria for patient selection, transplantation procedures, and outcome evaluations. Nowadays the high number of patients already treated allows us to draw initial conclusions related to clinical efficacy. After careful monitoring of the available data and improvement of the procedure, safety seems not to be anymore an issue. Ethics of HSCT deserve, on the contrary, a profound evaluation: the procedure is a multistep process with manifold options, each step with different ethical implications. Even more difficult appears the definition of the MS patient selection criteria for HSCT. The informed consensus needs to be exhaustive for the full comprehension of a complex procedure. In conclusion, although HCST is today an established therapeutical option for MS patients, safety and ethical issues need to be further clarified.     

Pharmacoeconomic analysis of sertraline treatment of depression in patients with unstable angina or a recent myocardial infarction

BACKGROUND: The prevalence of major depressive disorder in patients with acute coronary syndromes (ACSs) is high and associated with worse cardiovascular outcomes and higher health care costs. Sertraline is the only treatment for major depressive disorder studied in a placebo-controlled trial of patients with ACS and found to be safe and effective. The cost implications of providing antidepressant treatment in this population have not yet been examined. The objective was to evaluate from a payer perspective the potential reduction in costs and psychiatric and cardiovascular events and procedures following sertraline versus placebo treatment of major depressive disorder in patients hospitalized for ACS. METHOD: Data were analyzed from a randomized, double-blind, placebo-controlled 24-week trial (Sertraline Antidepressant Heart Attack Randomized Trial) of sertraline treatment for major depressive disorder in patients hospitalized for ACS. Main outcome measures included frequency and costs (derived from Medicare diagnosis-related group fee schedules) of psychiatric and cardiovascular events occurring during the treatment period. RESULTS: There was a trend toward significantly fewer psychiatric or cardiovascular hospitalizations in the sertraline compared with the placebo group (55/186 vs. 76/183; p = .054). The mean per patient cost associated with psychiatric and medical events over the course of treatment was 2733 US dollars for sertraline and 3326 US dollars for placebo, but the difference was not statistically significant (p = .32). After including the costs of the sertra-line (360 US dollars over 24 weeks), there was no increase in treatment costs for sertraline compared with placebo. CONCLUSION: Sertraline treatment of major depressive disorder following hospitalization for a recent myocardial infarction or unstable angina appears to be a cost-effective strategy.     

绵阳市规范管理的精神分裂症患者治疗效果的回顾性分析(英文)

背景 在过去的6年里,中国开展了世界上最大规模的重性精神病社区管理治疗项目(简称686项目),但项目实施的效果并未得到详细的评估。目的 对参与该项目的精神分裂症患者的临床有效者与临床无效者的特征进行比较。方法 从该项目的全国登记系统电子数据库中,提取2011年在四川省绵阳市(农村人口占60%)参加该项目的精神分裂症患者的资料,共3090份。根据精神科医生2011年的末次评估,将患者的疗效为"治愈"或"好转"者归为有效组(n=1866),将"无变化"或"加重"者归为无效组(n=1224),比较两组之间的社会人口学特征和治疗特点。收集的资料包括性别、年龄、民族、职业、文化程度、家庭经济状况、婚姻状况、精神疾病家族史、患病时间、参加686项目的时间以及治疗依从性等。结果 单因素分析结果显示,除性别、民族和精神疾病家族史外,其他因素的组间差异均有统计学意义。年龄小、病程短、受教育时间长、家庭经济状况好、治疗依从性好、参与686项目时间短的患者疗效更好。Logistic回归分析结果显示,服药依从性差、家庭贫困以及参加686项目时间长等因素更多见于疗效"无变化"或"加重"的患者。结论 治疗依从性差和家庭贫困严重地影响了686项目的效果。想方设法提高精神疾病患者的治疗依从性,向患者家庭提供基本的经济支持,将有助于提高该项目的成效。     

Treatment outcome and continuous quality improvement: two aspects of program evaluation

Increasingly, various stakeholders from insurance companies to patients are demanding verification of treatment effectiveness. With this pressure for accountability, program evaluation is essential to the continued existence of psychiatric hospitals because it permits understanding the effects specific interventions or procedures have on the quality and effectiveness of care. Two inpatient aspects of program evaluation are treatment outcome and continuous quality improvement. This article describes the conceptual bases of both treatment outcome and continuous quality improvement, depicts their complementary characteristics, and suggests how these two aspects of program evaluation can be integrated.     

The continuing care clinic: outpatient treatment of the chronically ill.

The need for continuing care of chronic psychiatric patients within the community is a pressing problem that calls for development and testing of new treatment methods. This paper describes one such method, the Continuing Care Clinic, an outpatient program for chronic patients who have not responded well to other outpatient treatment approaches. The clinic's structure, treatment rationale and procedures, and clinical results over a 31/2-year period are described. Among specific treatment features discussed are the use of multiple therapists, focus on available personality strengths and on reality issues, and patient-staff group interaction as an adjunct to individual psychotherapy.     

Assessment of health economics in Alzheimer's disease (AHEAD): treatment with galantamine in the UK

OBJECTIVE: To assess the long-term health and economic impact of treating mild to moderate Alzheimer's disease (AD) with galantamine (16 mg or 24 mg per day) compared to no cholinesterase therapy in the UK. METHODS: The long-term costs and outcomes were assessed using a model developed from longitudinal data on a cohort of AD patients. The model predicts the time until patients require full-time care, defined as the consistent requirement for a significant amount of care and supervision each day. Efficacy data were obtained from three clinical trials comparing galantamine with placebo, forecasts were made for ten years. Costs were determined in 2001 British pounds and discounted at 6% per annum, while outcomes such as time to full-time care were discounted at 1.5%. RESULTS: Without pharmacological treatment, patients are expected to incur costs of 28,134 British pounds over ten years, 70% of costs accrue from providing full-time care. Galantamine (16 mg per day) is predicted to reduce the duration of the full-time care state by 12%; approximately five patients need to be treated to avoid one year of full-time care. The ten-year incremental costs per month of full-time care avoided average pound 192 British pounds per patient and 8,693 British pounds per QALY. Savings (1380 British pounds) are predicted for patients who continue treatment beyond six months and whose cognitive function is maintained or improved. Comparable results were estimated for the 24 mg dose. CONCLUSION: In addition to the clinical benefits associated with galantamine treatment, the savings predicted from delaying when full-time care is needed may offset the treatment costs.     

Postdischarge treatment costs following closure of a state geropsychiatric ward: comparison of 2 levels of community care

Objectives: The purposes of this study were to (1) examine the cost of community-based health care services for geropsychiatric inpatients discharged into the community after the closure of an inpatient state geropsychiatric unit and (2) compare costs for patients treated with extra support through an Expanded Community Services (ECS) program to patients treated traditionally. Method: This study was a 6-month prospective, observational analysis of 30 patients discharged in conjunction with a ward closure in October 2002 (17 patients were nonrandomly assigned to the ECS program, and 13, to standard care). We analyzed costs of care, mortality, and rehospitalization rates derived from Medicaid paid claims and other data sources and compared costs to an estimate of hospital costs had the patients not been discharged. Patients were discharged to various community placements including long-term care facilities, assisted living facilities, and adult family homes in Eastern Washington State. Results: Costs for community care were approximately half of estimated costs for hospital care. Patients treated in the ECS program, representing the most severely in-need discharges, had costs of care that were nonsignificantly higher than non-ECS patients but still significantly lower than estimated hospital care. No differences in mortality or rehospitalization rates were found between ECS and non-ECS patients. Conclusion: Costs of community care were significantly lower than hospital care. Quality of life for patients in the community settings versus the hospital was not assessed. The ECS program was able to maintain high-risk geropsychiatric patients in the community comparably to less severely ill patients at less than hospital costs. Recommendations are provided for ways to establish community treatment programs for deinstitutionalized elderly patients with serious mental illness.     

Smoking reduction during inpatient alcohol detoxification: a controlled clinical pilot trial

Health care professionals tend to advise alcohol dependent patients to quit tobacco consumption only after longer periods of alcohol abstinence. This recommendation reflects concerns that smoking intervention programs may adversely interfere with the outcome of ongoing alcohol detoxification and rehabilitation treatment. However, the issue of appropriate time windows for initiating changes of smoking behaviour in alcoholic patients is still in need of empirical evaluation. Thus the aim of the present study is to investigate whether alcohol dependent smokers may be able to reduce cigarette consumption very early during alcohol detoxification and rehabilitation treatment. We performed a non-randomized controlled clinical pilot trial with 56 female and male alcohol dependent smokers in an inpatient setting providing a 3-weeks alcohol detoxification program. 28 individuals received a smoking reduction program consisting of a 6-sessions approach in a group format following behavioural principles. For the control group of 28 individuals the program was not available. Tobacco consumption was assessed daily by staff members. Alcohol dependent patients participating in the smoking reduction program reduced their daily cigarette consumption rates significantly, whereas the control group showed a tendency to increase tobacco consumption. According to the tentative findings of this pilot study early smoking interventions already during alcohol detoxification appear to be a feasible approach.     

Implicit preadmission screening criteria in an alcoholism treatment program.

The fact that alcoholism programs are biased in terms of the kind of patients admitted to treatment is well recognized. The authors examined the possible bias of preadmission screening procedures in an alcoholism treatment program and investigated some of the criteria used by staff clinicians in determining an applicant's acceptability for treatment. They found that accepted and rejected applicants had highly similar characteristics, differing only in age (accepted applicants were slightly younger than those rejected) and source of referral. The overall findings suggest that clinicians implicitly evaluate problem drinkers along dimensions related to their perceived "treatability" in a given therapeutic setting.     

Cost Assessment of a School-Based Mental Health Screening and Treatment Program in New York City

Although school-based mental health screening and treatment programs have been proposed as a viable means of reaching youth with unmet mental health needs, no previous reports have attempted to comprehensively document the costs of such programs. The purposes of this report are (1) to estimate the cost of a school-based mental health screening and treatment program in a real-world school setting, and (2) to outline the methods and procedures that should be employed by future investigators to explore the costs of such programs. The program, located in a middle school in a low-income, largely Hispanic neighborhood in New York City, aimed to screen all students in Grades 6-8 for anxiety, depression, and substance use disorders. Most students in need of treatment were referred to the school-based treatment program, where social workers offered individual and group counseling. Economic evaluation methods and a before/after study design were used to assess the costs of the screening and treatment programs for 3 years of operation. Costs were estimated from the societal perspective, which includes all measurable program costs regardless of who bears the costs, and the school perspective, which includes only costs that would be borne directly by a school operating these programs. Data primarily came from administrative records and staff interviews. The total cost ranged from 106,125 dollars to 172,018 dollars for the screening program and from 420,077 dollars to 468,320 dollars for the treatment program. The cost of the screening program ranged from 149 dollars to 234 dollars per student and the cost of the treatment program ranged from 90 dollars to 115 dollars per session. These costs were estimated from the perspective of society. Applying economic cost analysis methods in a real-world school setting is challenging, but the process can generate useful estimates. Cost analyses and cost-effectiveness studies are needed in this area.     

Depressive disorders: treatment patterns and costs of treatment in the private sector of the United States

The purpose of this paper is to examine the treatment patterns and costs of treatment for depressive disorders in the private sector of the United States. Based on the 1987–1989 calendar year MEDSTAT claim data, 40,898 patients were identified with a principal diagnosis of depressive disorder. Among a list of CPT-4 code procedures, individual psychotherapy had the highest frequency of usage followed by individual visits. Compared to individual psychotherapy, group/family psychotherapy had a much lower frequency of usage. Very few diagnostic episodes had laboratory work. In inpatient settings, costs of physician procedures and laboratory services were 2 times greater for patients with major depression or bipolar disorder than for patients with depression not otherwise specified (NOS) or dysthymic disorder. As expected, costs varied widely per episode. As the severity of illness increased, the cost variation became wider.     

Cost-effectiveness of systematic depression treatment among people with diabetes mellitus

CONTEXT: Depression co-occurring with diabetes mellitus is associated with higher health services costs, suggesting that more effective depression treatment might reduce use of other medical services. OBJECTIVE: To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among outpatients with diabetes. DESIGN: Randomized controlled trial comparing systematic depression treatment program with care as usual. SETTING: Primary care clinics of group-model prepaid health plan. PATIENTS: A 2-stage screening process identified 329 adults with diabetes and current depressive disorder. INTERVENTION: Specialized nurses delivered a 12-month, stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program. Subsequent treatment (combining psychotherapy and medication, adjustments to medication, and specialty referral) was adjusted according to clinical response. MAIN OUTCOME MEASURES: Depressive symptoms were assessed by blinded telephone assessments at 3, 6, 12, and 24 months. Health service costs were assessed using health plan accounting records. RESULTS: Over 24 months, patients assigned to the intervention accumulated a mean of 61 additional days free of depression (95% confidence interval [CI], 11 to 82 days) and had outpatient health services costs that averaged $314 less (95% CI, $1007 less to $379 more) compared with patients continuing in usual care. When an additional day free of depression is valued at $10, the net economic benefit of the intervention is $952 per patient treated (95% CI, $244 to $1660). CONCLUSIONS: For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.     

A randomised controlled trial of cognitive behaviour therapy vs treatment as usual in the treatment of mild to moderate late life depression

OBJECTIVES: This study provides an empirical evaluation of Cognitive Behaviour Therapy (CBT) alone vs Treatment as usual (TAU) alone (generally pharmacotherapy) for late life depression in a UK primary care setting. METHOD: General Practitioners in Fife and Glasgow referred 114 Participants to the study with 44 meeting inclusion criteria and 40 participants providing data that permitted analysis. All participants had a diagnosis of mild to moderate Major Depressive Episode. Participants were randomly allocated to receive either TAU alone or CBT alone. RESULTS: Participants in both treatment conditions benefited from treatment with reduced scores on primary measures of mood at end of treatment and at 6 months follow-up from the end of treatment. When adjusting for differences in baseline scores, gender and living arrangements, CBT may be beneficial in levels of hopelessness at 6 months follow-up. When evaluating outcome in terms of numbers of participants meeting Research Diagnostic Criteria for depression, there were significant differences favouring the CBT condition at the end of treatment and at 3 months follow-up after treatment. CONCLUSIONS: CBT alone and TAU alone produced significant reductions in depressive symptoms at the end of treatment and at 6 months follow-up. CBT on its own is shown to be an effective treatment procedure for mild to moderate late life depression and has utility as a treatment alternative for older people who cannot or will not tolerate physical treatment approaches for depression.     

Maintenance as treatment: the Fennell Program Day Centre

After discussing maintenance as an appropriate treatment philosophy for treating the long-term chronically mentally disabled, the authors describe a day centre based on this approach. Resources and costs, the target population, clients and their needs, activities, and referral and back-up procedures are reviewed. The article concludes with a look at some of the problem areas and benefits involved in a program using a maintenance approach.     

Multidisciplinary treatment of eating disorders--Part 1: Structure and costs of treatment

This article describes the structure and costs of a multidisciplinary hospital-based program for severe eating disorders. The program utilizes multiple levels of care (inpatient, partial day hospital, intensive outpatient, and traditional outpatient) to provide continuity of care during the recovery process, which often spans 2 to 3 months of intensive treatment. Details about the expectations of staff, patients, and family members are provided. Also, special protocols for refeeding, weight gain, and motivation for eating are described. The costs of treatment can be managed by greater utilization of the partial day hospital level of care, as opposed to lengthy inpatient hospitalization.