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.

Cost-effectiveness analysis of the treatment of posttraumatic stress disorder related to childhood abuse: comparison of phase-based treatment and direct trauma-focused treatment

“…In contrast to the purported assumption that STAIR would increase day-to-day functioning by addressing interpersonal and emotion regulation problems (Haasija and Cloitre, 2015), the present results do not show the advantage of adding this treatment to EMDR therapy in terms of cost-effectiveness. In contrast to the study by Kullberg et al (2023), we found a significant difference in mean societal costs between phase-based and direct trauma-focused conditions, with higher societal costs for phase-based treatment. The costs for PE and STAIR-PE appeared to be much higher (€ 4,479 and € 4,464, respectively) than those for EMDR and STAIR-EMDR (€ 1,686 and € 2,436, respectively).…”

“…A recent study examined the cost-effectiveness of prolonged exposure (PE) therapy preceded by STAIR among patients with PTSD related to childhood abuse (Kullberg et al, 2023). Unfortunately, the researchers did not answer the question of whether the addition of STAIR to trauma-focused treatment leads to economic benefits because of the skills gained during the preparation phase.…”

Data_Sheet_1.docx

“…In contrast to the purported assumption that STAIR would increase day-to-day functioning by addressing interpersonal and emotion regulation problems (Haasija and Cloitre, 2015), the present results do not show the advantage of adding this treatment to EMDR therapy in terms of cost-effectiveness. In contrast to the study by Kullberg et al (2023), we found a significant difference in mean societal costs between phase-based and direct trauma-focused conditions, with higher societal costs for phase-based treatment. The costs for PE and STAIR-PE appeared to be much higher (€ 4,479 and € 4,464, respectively) than those for EMDR and STAIR-EMDR (€ 1,686 and € 2,436, respectively).…”

“…However, the QALY outcomes in the study by Mavranezouli et al were measured over a different period of time (3 years) than in our study (9 months), so in comparing both outcomes, many assumptions had to be made, which leaves much uncertainty. The QALY's gained with EMDR seem somewhat lower than those for Prolonged Exposure from the study by Kullberg et al (2023); however, also in this case, many assumptions had to be made.…”

“…A recent study examined the cost-effectiveness of prolonged exposure (PE) therapy preceded by STAIR among patients with PTSD related to childhood abuse (Kullberg et al, 2023). Unfortunately, the researchers did not answer the question of whether the addition of STAIR to trauma-focused treatment leads to economic benefits because of the skills gained during the preparation phase.…”