Resumo

LARA-MUNOZ, María del Carmen et al. Cost-effectiveness study of depression management in Mexico. Salud Ment [online]. 2010, vol.33, n.4, pp.301-308. ISSN 0185-3325.

Introduction Depression is a public health problem that carries substantial costs for the individual and the society. In order to establish evidence-based priorities for resource allocation in mental health care, it is necessary to integrate the costs and effectiveness of interventions and specify the essential packages for their treatment. The following are pioneering studies of cost-effectiveness for the treatment of depression: 1. compared psychopharmacology options (fluoxetine, imipramine and desipramine) to found no difference between drugs in terms of clinical efficacy, effect on quality of life and costs, and 2. evaluated cost-effectiveness of collaborative program of stepped care in primary care of persistent depression, to demonstrate a substantial increase in the effectiveness and additional moderate cost increase in comparison with usual treatment. Recently, the World Health Organization convened the National Institute of Psychiatry Ramón de la Fuente, as a collaborating center, to participate in the <<Selecting interventions that are cost-effective>> labeled WHO-CHOICE (CHOosing interventions that are Cost-Effective). This paper presents the findings of the evaluation of cost-effectiveness of different clinical interventions for the treatment of depression in Mexico, considering its implementation in primary care services. Method The cost-effectiveness unit of measure gathered by WHO (and used in this work) are the years of healthy life lost because of disease, named DALYs (Disability Adjusted Life Years). DALYs result from the sum of years lost by premature mortality over the years that are lost through living in disability status. The advantages of using a measure of health at the population level as lost DALYs is that it allows comparing interventions for different diseases and addresses a relevant question from the avoidable burden health policy standpoint. Interventions evaluated included: 1. tricyclic antidepressants, 2. new antidepressants (SSRIs), 3. brief psychotherapy, 4. trycliclic antidepressants + brief psychotherapy, 5. new antidepressants + brief psychotherapy, 6. tricyclic antidepressants + brief psychotherapy + proactive case management, and 7. new antidepressants + brief psychotherapy + proactive case management. DALYs avoided as a result of each intervention or combination were calculated to determine its effectiveness. Both patients and program costs, a 3% discount by the process of converting future values to present ones, as well as an age adjustment giving less weight to year lived by the young were included. Finally, the cost of averted DALYs for each intervention was estimated to determine their cost effectiveness. Results The combined strategies of proactive case management with psychotherapy plus antidepressants can be considered as the most effective one. With the combination with tricyclic antidepressants, the number of DALYs averted was 207,1 71, and with SSRI of 21 7,568, corresponding to more than double of DALYs when tricyclic anti-depressants are used alone and almost double when using only SSRIs. The most expensive intervention was the combination of SSRIs with brief psychotherapy, with a total of $12,256 million pesos (972 million dollars), the least expensive treatment were tricyclic antidepressants, which involved $4,523 million pesos (359 million dollars). Over 99% of the costs were from patient medications, and less than 1% from program and training costs. It is clear that the greatest cost is for added proactive case management. The use of SSRI was the most cost-effective treatment (no combination) for the management of depression in Mexican primary care. The most cost-effective combination was tryciclic antidepressants plus brief psychotherapy plus proactive case management. Conclusions Although the are some studies on health economics in Mexico, most are directed to consider costs, and few ones have evaluated the cost-effectiveness relationship of diagnostic and therapeutic interventions, lees son in the mental health field. Antecedents of the present study in Mexico included a study that observed that psychiatric patients require more medical consultations, laboratory analysis, hospitalization days, surgeries and medication, in contrast with patients that never needed mental attention. Nevertheless, investigations about cost-effectiveness relationship are rare. Just one study evaluates the costs of positive changes in psychopathology with antipsychotic medication for the treatment of schizophrenic patients. In this direction, the present work is the first effort to evaluate cost-effectiveness of different communitarian interventions to treat depression in Mexico. According with our findings, also in México, the interventions available to treat depression in primary care level prevent a substantial number of DALYs: almost six times when SSRIs plus brief psychotherapy plus proactive case management are administered. The specific effect of proactive case management is preventing relapses and increasing the time free of disease, which results in greater benefit to the patient, his family and the society. Thus, interventions are cost-effective despite the proactive case management significantly increases the cost of care to these patients. In conclusion, the inclusion of psychosocial treatments is advantageous from a cost-effectiveness standpoint. Averted DALYs with these interventions are more <<economic>>. As observed in previous studies, a modest investment in improving depression produces greater gains in resource-limited environments. In Mexico, there is evidence that such interventions in primary care are effective when they are given by medical staff with a brief training, making them a promising tool for a cost-effective and evidence-based public policy.

Palavras-chave : Depression; treatment; cost-effectiveness.

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