Exposure-based treatments for childhood abuse-related post-traumatic stress disorder in adults: a health-economic evaluation

Abstract

Background: Prolonged exposure (PE) is an effective treatment for post-traumatic stress disorder (PTSD).Objective: This study aimed to analyse the cost-effectiveness of three exposure-based treatments in patients with childhood abuse-related PTSD.Method: A net-benefit analysis was conducted alongside a pragmatic randomized controlled trial with participants (N = 149) randomized to three conditions: PE (n = 48), intensified PE (i-PE, n = 51), and phase-based PE [Skills Training in Affective and Interpersonal Regulation (STAIR) + PE, n = 50]. Assessments took place at baseline (T0), post-treatment (T3), 6 month follow-up (T4), and 12 month follow-up (T5). Costs stemming from healthcare utilization and productivity losses were estimated using the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness. Quality-adjusted life-years (QALYs) were based on the 5-level EuroQoL 5 Dimensions (EQ-5D-5L) using the Dutch tariff. Missing values of costs and utilities were multiply imputed. To compare i-PE to PE and STAIR + PE to PE, pair-wise unequal-variance t-tests were conducted. Net-benefit analysis was used to relate costs to QALYs and to draw acceptability curves.Results: Intervention costs did not differ across the three treatment conditions. Total medical costs, productivity losses, total societal costs, and EQ-5D-5L-based QALYs did not differ between treatment conditions either (all p > .10). At the relevant €50,000/QALY threshold, the probability of one treatment being more cost-effective than another was 32%, 28%, and 40% for PE, i-PE, and STAIR-PE, respectively.Conclusion: Three equally effective treatments were compared and no differences in cost-effectiveness between treatments were found. Therefore, we advocate the implementation and adoption of any of the treatments and endorse shared decision making.

Keywords: PTSD; TEPT; abuso infantil; childhood abuse; cost-effectiveness; costo-efectividad; exposición prolongada; net-benefit analysis; prolonged exposure; 延长暴露; 成本效益; 童年期虐待.

Figure 1.

Average utility through the year, according to (A) the 5-level EuroQol 5 Dimensions (EQ-5D-5L) and (B) the visual analogue scale (VAS). T0 = Baseline; T1 = after 4 weeks (4 sessions of STAIR + PE or PE or 12 sessions of i-PE); T2 = after 8 weeks (8 sessions of STAIR + PE or PE or 13 sessions of i-PE); T3 = after 16 weeks (i.e. post-treatment); T4 = 6 month follow-up (26 weeks); T5 = 12 month follow-up (52 weeks). PE, prolonged exposure; i-PE, intensified prolonged exposure; STAIR, Skills Training in Affective and Interpersonal Regulation.

Figure 2.

Cost-effectiveness acceptability curves, i.e. the probability that each of the conditions is economically preferred over the other two conditions, depending on the willingness to pay per quality-adjusted life-year (QALY). (A) Base-case analysis, based on societal costs and QALYs estimated from the 5-level EuroQol 5 Dimensions (EQ-5D-5L); (B) sensitivity analysis based on intervention costs (instead of societal costs) and QALYs estimated from the EQ-5D-5L; (C) sensitivity analysis based on societal costs and QALYs estimated from the visual analogue scale (instead of the EQ-5D-5L).