The Cost Effectiveness of Psychological and Pharmacological Interventions for Social Anxiety Disorder:A Model-Based Economic Analysis

Background Social anxiety disorder is one of the most persistent and common anxiety disorders. Individually delivered psychological therapies are the most effective treatment options for adults with social anxiety disorder, but they are associated with high intervention costs. Therefore, the objective of this study was to assess the relative cost effectiveness of a variety of psychological and pharmacological interventions for adults with social anxiety disorder. Methods A decision-analytic model was constructed to compare costs and quality adjusted life years (QALYs) of 28 interventions for social anxiety disorder from the perspective of the British National Health Service and personal social services. Efficacy data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published literature and national sources, supplemented by expert opinion. Results Individual cognitive therapy was the most cost-effective intervention for adults with social anxiety disorder, followed by generic individual cognitive behavioural therapy (CBT), phenelzine and book-based self-help without support. Other drugs, group-based psychological interventions and other individually delivered psychological interventions were less cost-effective. Results were influenced by limited evidence suggesting superiority of psychological interventions over drugs in retaining long-term effects. The analysis did not take into account side effects of drugs. Conclusion Various forms of individually delivered CBT appear to be the most cost-effective options for the treatment of adults with social anxiety disorder. Consideration of side effects of drugs would only strengthen this conclusion, as it would improve even further the cost effectiveness of individually delivered CBT relative to phenelzine, which was the next most cost-effective option, due to the serious side effects associated with phenelzine. Further research needs to determine more accurately the long-term comparative benefits and harms of psychological and pharmacological interventions for social anxiety disorder and establish their relative cost effectiveness with greater certainty

Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis

SummaryBackgroundSocial anxiety disorder—a chronic and naturally unremitting disease that causes substantial impairment—can be treated with pharmacological, psychological, and self-help interventions. We aimed to compare these interventions and to identify which are most effective for the acute treatment of social anxiety disorder in adults.MethodsWe did a systematic review and network meta-analysis of interventions for adults with social anxiety disorder, identified from published and unpublished sources between 1988 and Sept 13, 2013. We analysed interventions by class and individually. Outcomes were validated measures of social anxiety, reported as standardised mean differences (SMDs) compared with a waitlist reference. This study is registered with PROSPERO, number CRD42012003146.FindingsWe included 101 trials (13 164 participants) of 41 interventions or control conditions (17 classes) in the analyses. Classes of pharmacological interventions that had greater effects on outcomes compared with waitlist were monoamine oxidase inhibitors (SMD −1·01, 95% credible interval [CrI] −1·56 to −0·45), benzodiazepines (−0·96, −1·56 to −0·36), selective serotonin-reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors (SSRIs and SNRIs; −0·91, −1·23 to −0·60), and anticonvulsants (−0·81, −1·36 to −0·28). Compared with waitlist, efficacious classes of psychological interventions were individual cognitive–behavioural therapy (CBT; SMD −1·19, 95% CrI −1·56 to −0·81), group CBT (−0·92, −1·33 to −0·51), exposure and social skills (−0·86, −1·42 to −0·29), self-help with support (−0·86, −1·36 to −0·36), self-help without support (−0·75, −1·25 to −0·26), and psychodynamic psychotherapy (−0·62, −0·93 to −0·31). Individual CBT compared with psychological placebo (SMD −0·56, 95% CrI −1·00 to −0·11), and SSRIs and SNRIs compared with pill placebo (−0·44, −0·67 to −0·22) were the only classes of interventions that had greater effects on outcomes than appropriate placebo. Individual CBT also had a greater effect than psychodynamic psychotherapy (SMD −0·56, 95% CrI −1·03 to −0·11) and interpersonal psychotherapy, mindfulness, and supportive therapy (−0·82, −1·41 to −0·24).InterpretationIndividual CBT (which other studies have shown to have a lower risk of side-effects than pharmacotherapy) is associated with large effect sizes. Thus, it should be regarded as the best intervention for the initial treatment of social anxiety disorder. For individuals who decline psychological intervention, SSRIs show the most consistent evidence of benefit.FundingNational Institute for Health and Care Excellence

Health psychology interventions to improve adherence to maintenance therapies in asthma

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Main objectives To determine the effectiveness of theory-based and non-theory based health psychology interventions for improving adherence to maintenance therapy in adults with asthma Secondary objectives To compare the effectiveness of adherence interventions which are based on theory, as defined by the Theory Coding Scheme (TCS), to interventions which are not theory-based To identify and describe, using the TSC and Theoretical Domain Framework (TDF), the different health psychology theories which have been used in interventions to improve adherence to maintenance therapy in adults with asthma To evaluate the extent to which health psychology theory has been applied to the development of adherence interventions in asthm

Data management form: Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department

<p>Excel file contains all extracted data, including characteristics and numerical outcome data, that were used in the development of the Cochrane review:</p> <p>Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD010909. DOI: 10.1002/14651858.CD010909.pub2.</p> <p> </p> <p>Instructions for how to use and understand the file are given in the first worksheet 'Using this document'.</p

Two years down, one to go:an NIHR Programme Grant in numbers

Background There is more emphasis than ever on producing priority systematic reviews to a high standard as quickly as possible. This is a key element of Cochrane’s Strategy to 2020, and the focus of Production Models within Project Transform – Cochrane’s initiative to “improve the way people, processes, and technologies come together to produce Cochrane content”. Cochrane Airways started a three-year NIHR programme grant in May 2014 on the subject of asthma. We presented reassuring progress at the end of year 1 in Vienna, and listed aspects that sped up or slowed down development. Another year on and with a year to go, we have updated and extended the analyses. Objective To assess an NIHR programme grant as a production model in terms of productivity, authorship, resources, and impact. Methods We used Archie data to track the 25 programme grant titles and conduct analyses of median time taken to reach milestones. We collated data about PPI involvement, number and geography of contributing authors, resources, and impact (guideline inclusion, Altmetrics, podcasts and blogs). Conclusions The model continues to be an efficient way of producing priority reviews quickly in the Airways group. Resource implications may be a barrier to implementing the model more widely, and improvements are needed to enhance impact and inclusion, especially from authors in LMIC

Axitinib, cabozantinib, everolimus, nivolumab, sunitinib and best supportive care in previously treated renal cell carcinoma: a systematic review and economic evaluation

Background: Several therapies have recently been approved for use in the NHS for pretreated advanced or metastatic renal cell carcinoma (amRCC), but there is a lack of comparative evidence to guide decisions between them. Objective: To evaluate the clinical effectiveness and cost-effectiveness of axitinib (Inlyta®, Pfizer Inc., NY, USA), cabozantinib (Cabometyx®, Ipsen, Slough, UK), everolimus (Afinitor®, Novartis, Basel, Switzerland), nivolumab (Opdivo®, Bristol-Myers Squibb, NY, USA), sunitinib (Sutent®, Pfizer, Inc., NY, USA) and best supportive care (BSC) for people with amRCC who were previously treated with vascular endothelial growth factor (VEGF)-targeted therapy. Data sources: A systematic review and mixed-treatment comparison (MTC) of randomised controlled trials (RCTs) and non-RCTs. Primary outcomes were overall survival (OS) and progression-free survival (PFS). Secondary outcomes were objective response rates (ORRs), adverse events (AEs) and health-related quality of life (HRQoL). MEDLINE, EMBASE and The Cochrane Library were searched from inception to January and June 2016 for RCTs and non-RCTs, respectively. Two reviewers abstracted data and performed critical appraisals. Review methods: A fixed-effects MTC was conducted for OS, PFS [hazard ratios (HRs)] and ORR (odds ratios), and all were presented with 95% credible intervals (CrIs). The RCT data formed the primary analyses, with non-RCTs and studies rated as being at a high risk of bias included in sensitivity analyses (SAs). HRQoL and AE data were summarised narratively. A partitioned survival model with health states for pre progression, post progression and death was developed to perform a cost–utility analysis. Survival curves were fitted to the PFS and OS results from the MTC. A systematic review of HRQoL was undertaken to identify sources of health state utility values. Results: Four RCTs (n = 2618) and eight non-RCTs (n = 1526) were included. The results show that cabozantinib has longer PFS than everolimus (HR 0.51, 95% CrI 0.41 to 0.63) and both treatments are better than BSC. Both cabozantinib (HR 0.66, 95% CrI 0.53 to 0.82) and nivolumab (HR 0.73, 95% CrI 0.60 to 0.89) have longer OS than everolimus. SAs were consistent with the primary analyses. The economic analysis, using drug list prices, shows that everolimus may be more cost-effective than BSC with an incremental cost-effectiveness ratio (ICER) of £45,000 per quality-adjusted life-year (QALY), as it is likely to be considered an end-of-life treatment. Cabozantinib has an ICER of £126,000 per QALY compared with everolimus and is unlikely to be cost-effective. Nivolumab was dominated by cabozantinib (i.e. more costly and less effective) and axitinib was dominated by everolimus. Limitations: Treatment comparisons were limited by the small number of RCTs. However, the key limitation of the analysis is the absence of the drug prices paid by the NHS, which was a limitation that could not be avoided owing to the confidentiality of discounts given to the NHS. Conclusions: The RCT evidence suggests that cabozantinib is likely to be the most effective for PFS and OS, closely followed by nivolumab. All treatments appear to delay disease progression and prolong survival compared with BSC, although the results are heterogeneous. The economic analysis shows that at list price everolimus could be recommended as the other drugs are much more expensive with insufficient incremental benefit. The applicability of these findings to the NHS is somewhat limited because existing confidential patient access schemes could not be used in the analysis. Future work using the discounted prices at which these drugs are provided to the NHS would better inform estimates of their relative cost-effectiveness. Study registration: This study is registered as PROSPERO CRD42016042384. Funding: The National Institute for Health Research Health Technology Assessment programme

Cost-effectiveness plane showing the incremental costs and QALYs of all interventions versus wait list.

<p>Wait list is placed at the origin; results are for 1,000 adults with social anxiety disorder at 5 years after treatment. The continuous line shows the cost-effectiveness efficiency frontier, while the slope of the dotted line indicates the NICE lower cost effectiveness threshold (£20,000/QALY). The data used to construct Fig 2 are provided in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0140704#pone.0140704.t005" target="_blank">Table 5</a>.</p

Schematic diagram of the economic model constructed to assess the cost-effectiveness of interventions for social anxiety disorder.

<p>Schematic diagram of the economic model constructed to assess the cost-effectiveness of interventions for social anxiety disorder.</p

Results of network meta-analysis that were utilised in the economic model: probability of recovery at end of treatment.

<p>The log-odds of recovery on wait list was assumed to follow a normal distribution with mean -2.629 and variance 1.235 (estimated using all the wait list arms of RCTs included in the NMA); this translates into a probability of recovery for wait list (mean, 95% credible intervals) as shown above.</p><p>C&W: Clark and Wells model; GCBT: group cognitive behavioural therapy; ICBT: individually delivered cognitive behavioural therapy; IPT: interpersonal therapy; NMA: network meta-analysis; PDPT: psychodynamic psychotherapy; SHNS: self-help no support; SHWS: self-help with support</p><p>Interventions ranked according to probability of recovery (highest to lowest).</p