A Cost-Utility Analysis of Screening and Cognitive Behavioral Therapy compared to usual care for Perinatal Depression

doi:10.21203/rs.3.rs-4713926/v1

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A Cost-Utility Analysis of Screening and Cognitive Behavioral Therapy compared to usual care for Perinatal Depression

https://doi.org/10.21203/rs.3.rs-4713926/v1

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Background: Perinatal depression is common and the most prevalent cause of maternal mortality, implementing effective depression screening and therapy is a priority for public health internationally.

Objective: The aim of this study is to estimate the cost-effectiveness of implementing a strategy of perinatal depression screening with Cognitive Behavioral Therapy (CBT) compared with the current Treatment as Usual alone (TAU) for individuals with perinatal depression.

Methods: A decision tree model was constructed to estimate the potential cost and utility benefits for screening using the Whooley Questionnaire followed by referral to CBT compared to TAU alone in Hong Kong. The model used healthcare costs, in Hong Kong Dollars (HKD), and quality-adjusted life years (QALYs) to estimate economic and health utility outcomes. We used two states (remission, and depression) modeled over a single perinatal period, such as transfer probabilities, depression-specific quality of life, and cost data were retrieved from published studies. Deterministic and probabilistic sensitivity analyses were conducted to estimate the stability of the model.

Results: The baseline analysis suggested Whooley combined with CBT or TAU yielded an additional 0.02 QALY compared to TAU alone but added 900.26 HKD to the cost of treatment per patient. Our deterministic sensitivity analysis indicates several variables that have the greatest impact on the model. Our probabilistic sensitivity analysis shows that Whooley combined with CBT or TAU is approximately 84% more cost-effective than TAU alone at a willingness-to-pay (WTP) threshold of 194,780 HKD.

Conclusions: Whooley combined with CBT is estimated to be cost-effective in identifying and treating individuals with perinatal depression at an early stage compared to TAU alone. More research is required to assess the feasibility, cost-benefit, and clinical effectiveness of this strategy.

Perinatal Depression

Cost-Utility Analysis

Whooley Questionnaire

Cognitive Behavioral Therapy

Hong Kong

Monte Carlo Simulation

Perinatal depression is depression during pregnancy and up to a year after childbirth [1]. It affects approximately 20% of mothers globally [2]. An epidemiology study of 357 women in Hong Kong found that 18.9% of women in the second trimester and 22.1% in the third trimester suffered from depression [3]. Perinatal depression is a significant contributor to the burden of illness in mothers and newborns. It can result in a range of adverse health outcomes, including risk of poorer physical health, increased risk of smoking addiction or alcohol abuse. Perinatal depression can also impair the offspring’s cognitive development [4]. In addition, perinatal depression carries a huge financial burden, with it estimated that a case of perinatal depression costs up to £74,000 over the perinatal period [5]. Therefore, identifying and treating perinatal depression in the early stage is crucial to the health of individuals and infants.

The Whooley questionnaire consisted of two short questions, with the third question being enabled if the patients answered yes to either of the first two questions [6]. This tool can be used in detecting likely cases of perinatal depression; a recent meta-analysis found that compared with other screening tools, the advantage of the Whooley questionnaire is that it requires less time and resources to administer, making it more accessible to the healthcare system when time and resources are limited [7]. A study conducted in Hong Kong on the diagnostic properties of the Whooley questionnaire found that it was reliable in identifying pregnant women at high risk of depression [8]. Additionally, the National Institute for Health and Care Excellence (NICE) also recommended using the Whooley questionnaire to identify perinatal depression [9]. It is beneficial to screen all pregnant women before specific treatment.

Cognitive Behavioral Therapy (CBT) is a form of psychotherapy that helps individuals modify negative thought patterns and behaviors [10]. Plenty of studies support the effectiveness of CBT for the treatment of perinatal depression in clinical settings [10–12]. In several randomized controlled trials (RCT), CBT not only relieved mothers' depressive symptoms but also reduced the risk of future relapse [13], where it was most effective for cases of mild to moderate depression [14]. In addition, a study noted [11] that CBT-based interventions also have significant effects on other symptoms, such as anxiety, and stress. Compared to pharmacotherapy, CBT reduces depression through psychological counseling and spiritual comforting, has fewer health side effects, and is therefore more easily accepted [15]. Some experts suggest that CBT should be included in the standard perinatal care process [16, 17]. Although the clinical effectiveness of CBT has been widely reported, the cost-benefit outcome of CBT for perinatal depression in healthy economic areas has not yet been explored [10–17].

Cost-utility analysis (CUA) is a specific form of cost-effectiveness analysis that compares the relative costs and outcomes (often measured in quality-adjusted life years (QALYs)) of different treatment strategies for depression [18]. Several research has assessed the cost-effectiveness of screening and CBT for a wide range of psychiatric disorders [18–20]. However, none of the studies combined the screening with the treatment to assess the cost-effectiveness in perinatal depression or based on a Hong Kong setting. Previous studies on health economics and perinatal depression primarily evaluated by applying disease-specific outcome criteria like "cost per additional successfully treated patient" [21] instead of QALYs [22]. This poses a significant challenge for subsequent studies to merge health economics indicators and conduct relevant meta-analyses. To bridge this gap in research and provide relevant stakeholders with information to aid decision-making, we conducted this CUA based on a decision-tree model. We have modelled for implementing a combination of the Whooley questionnaire for screening cases and CBT for treatment then compared this strategy to the current TAU. Using the incidence rate of perinatal depression of depression in the Hong Kong region as a key parameter of the model, to assess its cost-effectiveness.

Model Structure and Assumptions

We estimated the cost-effectiveness of introducing the Whooley questionnaire for screening and CBT compared with TAU alone for treating perinatal depression over a single perinatal period using a hypothetical decision tree model. We defined a single perinatal period up to 1 year postpartum. As Hong Kong was the setting for our economic model all costs were calculated using Hong Kong Dollars (HKD). This model was split into two parts, TAU and Whooley screening with possible CBT, and there was one cycle in the entire perinatal period (pregnancy to 1 year postpartum). The model divided 50% of individuals who received TAU or screening using the Whooley questionnaire. In the TAU arm, individuals may or may not have depression, if they have depression, they may remain stable or in remission; if they don’t have depression, they may stay stable or may develop depression after treatment. In the Whooley arm, individuals may have depression. This may or may not be detected by the Whooley, there is also the risk of false positive. Those receiving screening with a positive result for depression would be offered CBT, although it is assumed not all would participate in CBT, they will receive TAU. For those that accept CBT, we assumed to complete 10 sessions at any time during the antenatal period. For false positives and true positives, we assumed some would participate in CBT, and the rest of the patients (true negative and false negative) would participate in TAU.

The probability of perinatal mothers suffering from depression was assumed to be the same as that of the incidence rate in Hong Kong reported in survey data studies. TAU and CBT were considered the current practice in Hong Kong for treating perinatal depression. Due to currently available study data limitations, we did not account for the additional health and economic costs associated with false negative and false positive results. In our model, we defined two possible outcomes post-treatment: remission or no remission of depression (regardless of severity). Since the entire model continues only the perinatal period, we did not include the risk of death for individuals. This model structure of this study is shown in Fig. 1.

The parameters required for this model are presented in 6 sections. For each part, priority was given to the research on the perinatal depression of Hong Kong mothers. When lacking relevant data, we considered the results of research from other countries or regions, where possible studies from similar economies, cultures, and healthcare systems were used. For the same parameter, if different values were reported across studies, the median was used as the baseline analysis parameter, and the reported upper and lower values were used in the deterministic sensitive analysis. For parameters taken from meta-analysis or other studies, we selected the pooled values and 95% confidence intervals for analysis. For probabilistic sensitivity analysis, we constructed the appropriate distributions for the collected data.

Parameter Estimated

2.1.1 Transition Probabilities

We defined the effectiveness of TAU and CBT as the proportion of mothers who experienced treatment-induced remission of depression (excluding spontaneous remission). At the same time, the models also considered treatment failure (remission to depression). To make the parameters of the model more reliable, we collected 34 published and peer-reviewed literature involving evaluating CBT compared to TAU for perinatal depression.

We excluded studies that did not report patient depression remission and dropout rates, specify whether Face-to-Face CBT (FCBT) and TAU that were performed in clinic settings, mothers had severe comorbidities (e.g., epilepsy or HIV), included CBT combined with other active treatments (e.g., medication), and studies that were exclusively focused on specific ethnicities. After screening for articles in MEDLINE, there were 19 studies reporting effectiveness rates and relapse rates for TAU and CBT for perinatal depression [10, 11, 23–40]. Subsequently, we summarized this data and provided additional details to estimate parameters. After completing one treatment cycle, the pooled remission rate for CBT was 0.746, while the pooled remission rate for TAU was 0.423. Additionally, the pooled relapse rate for CBT was 0.089, and for TAU, it was 0.267.

2.1.2 Incidence Rate of Perinatal Depression

In Hong Kong, perinatal depression is estimated to affect 20% of individuals [41–48]. According to this information, we adjusted the model parameters to reflect this real-life scenario. We collected 8 relevant literature sources reporting the incidence rate in Hong Kong [41–48]. The stages of perinatal depression included prenatal, postpartum, and perinatal depression. The screening method was structural psychological interviews administered by healthcare providers. After excluding literature that did not report patient dropout rates and mothers with severe comorbidities, we identified a pooled incidence rate of perinatal depression in our model as 0.197 (19.7%).

2.1.3 Specificity and Sensitivity of Whooley Questionnaire (True-Negative and True-Positive)

For the specificity and sensitivity of the Whooley questionnaire, the results of a meta-analysis were utilized that examined the diagnostic validity in perinatal depression [7]. A total of 10 studies were included in the review. All studies were included in the meta-analysis section and the heterogeneity of these studies was low. The pooled sensitivity and specificity in this study were employed in the decision model for estimating parameters for true positive, false positive, true negative, and false negative (sensitivity 0.950, specificity 0.650) [7].

2.1.4 Willingness to Accept CBT

At present, no data for estimating the acceptance rates of perinatal individuals’ willingness to receive CBT after screening positive for the Whooley questionnaire have been reported. To estimate the acceptance rate of CBT in perinatal individuals 13 RCTs evaluating CBT were used, the acceptance rate was based on the number of individuals who declined during the recruitment to take part in the study, as a proxy for mothers' willingness to accept CBT [25, 49–60]. We excluded studies that failed to report the recruitment process or failed to report the number of samples that declined to enter the study. We found that the willingness of perinatal mothers to accept CBT therapy varied greatly due to differences in samples, and experimental designs. The acceptance rates ranged from 0.273 to 0.980 without any consistent pattern [25, 49–60]. Therefore, we selected the median 0.566 as the baseline parameter.

2.1.5 Measurement of Costs

We were unable to collect any model-eligible cost data for FCBT for perinatal individuals directly from studies conducted in Hong Kong. Therefore, the cost parameters for the model were extracted from an RCT which included a cost-effectiveness analysis conducted [61] in 2014 in Japan. The study spanned approximately 64 weeks and was divided into two phases. We selected the second period of cost data that was more consistent with the model assumptions and expanded the FCBT cost to 10 sessions of treatment. For the cost of performing the Whooley questionnaire screening, we selected data from a study conducted in the United Kingdom, which estimated that the Whooley questionnaire screening takes 1.71 minutes at a cost of professional nurses to administer between £0.92 and £2.65 [62]. We examined the International Monetary Funds’ published inflation rates for the Japanese yen from 2014 to 2023, the purchasing power evaluation of the Japanese yen for 2023, the inflation rate for the British pound from 2014 to 2023, and the purchasing power evaluation of the British pound for 2023 to convert relevant costs. After calculation, the inflation factor for the Japanese yen from 2014 to 2023 was 1.078, and the British pound inflation coefficient from 2014 to 2023 was 1.227 [63–65]. Therefore, in 2023, 1 yen was equivalent to 0.05584 HKD, and £1 was equivalent to 9.739 HKD [63–65].

We modeled for TAU and CBT to be conducted in a clinical setting. The total perinatal period cost of TAU was divided into consultation and medication components, while CBT was divided into consultation, medication, and administration of CBT components. In the cost of a single session, the cost of routine counseling (37.29 HKD) and psychiatric administration (170.91 HKD) were assigned to the consultation cost component. The cost of prescriptions (61.63 HKD) and the cost of average daily weighted clinical medication (40.74 HKD) were assigned to the medication component. The CBT component only included the cost of treatments associated with the CBT in each session (248.59 HKD). A single session of CBT was estimated to last 50 minutes, conducted by a healthcare provider [61]. After collecting all estimated costs, the Whooley screening cost was 35.97 HKD, the consultation components of CBT and TAU were predicted as 4,242.97 HKD and 4,195.79 HKD respectively, the medication component as 4,810.12 HKD and 4,185.33 HKD respectively, and the total CBT component as 2589.48 HKD over a perinatal period.

2.1.6 Health Utility

In our model, we used quality-adjusted life years (QALYs) to represent the post-treatment effects and utilize the data extracted as quality-of-life weights. Since the entire model lasted only one period, we assumed that the QALYs of the sample did not change during the perinatal period. No study was identified that reported that are fully compatible with assessing the QALYs for perinatal depression. Therefore, a pharmacoeconomic study about depression was used to estimate the utility of our study [66]. The study assessed the status of patients in various stages of depression. Based on their health status, the patients were divided into two groups: those with mild to moderate depression and those in depression remission. The mean utility scores for patients with depression were estimated at 0.63 QALYs and 0.86 QALYs for depression remission during treatment [66]. All model parameters in this study are shown in Table 1

Table 1

Model parameters used in the health economic model
Model Parameter	Baseline	Standard Deviation	Distribution Type	Deterministic		Source
Model Parameter	Baseline	Standard Deviation	Distribution Type	Low	High	Source
Cost (HKD)
Unit cost of each healthcare service
Routine counseling (per visit)	37.29	-	-	-	-	[61]
Psychiatric administration fee (per visit)	170.91	-	-	-	-	[61]
Prescription fee (per prescription)	61.63	-	-	-	-	[61]
CBT (per session)	248.59	-	-	-	-	[61]
Average daily weighted clinical medication	40.74	-	-	-	-	[61]
Cost of whole stage (10 sessions)
TAU
Consultation cost	4195.79	2746.20	Gamma	3344.74	5046.85	[61]
Medication cost	4185.33	3235.04	Gamma	3182.78	5187.88	[61]
Whooley combined with CBT
Consultation cost	4242.97	2363.37	Gamma	3510.56	4975.39	[61]
Medication cost	4810.12	3361.36	Gamma	3768.43	5851.82	[61]
Administration of CBT	2589.48	1906.20	Gamma	1998.74	3180.22	[61]
Whooley screening cost (per person)	35.97	68.15	Gamma	14.85	57.09	[62]
Whooley combined with TAU
Consultation cost	4195.79	2746.20	Gamma	3344.74	5046.85	[61]
Medication cost	4185.33	3235.04	Gamma	3182.78	5187.88	[61]
Whooley screening cost (per person)	35.97	68.15	Gamma	14.85	57.09	[62]
Incidence rate in Hong Kong	0.197	-	Beta	0.155	0.262	[41–48]
Screening accuracy
True negative	0.650	0.290	Beta	0.560	0.740	[7]
True positive	0.950	0.145	Beta	0.880	0.970	[7]
Transition probabilities
CBT group
Depression to remission	0.746	-	Beta	0.628	0.838	[10, 11, 23–29]
Remission to depression	0.089	-	Beta	0.047	0.135	[26, 30–32, 39, 40]
TAU group
Depression to remission	0.423	-	Beta	0.326	0.524	[11, 23–25, 27, 33–37]
Remission to depression	0.267	-	Beta	0.182	0.346	[30–32, 38, 39]
Willingness to accept CBT	0.566	-	Uniform	0.273	0.980	[25, 49–60]
Health utility (QALYs)
Depression	0.630	0.174	Beta	0.576	0.684	[66]
Remission	0.860	0.121	Beta	0.823	0.897	[66]

Table 1. Model parameters used in the health economic model

Sensitivity Analyses

This study involved synthesizing data from various sources, forms of error, and model uncertainty had to be assessed in a multivariate approach using various assumptions. To account for uncertainty in the model parameters, we conducted deterministic and probabilistic sensitivity analyses. For the deterministic model, we used 95% confidence intervals of various reported cost values, specificity and sensitivity of the Whooley questionnaire and patients' QALYs, as well as the reported minimum and maximum values for willingness to accept CBT, transition probabilities, and the incidence rate of perinatal depression. For the probabilistic sensitivity analysis, we conducted 10,000 Monte Carlo simulation repetitions. We randomly selected input parameters from the Gamma distribution (cost of treatment), Beta distribution (sensitivity and specificity of the Whooley questionnaire, QALY values, transition probabilities, incidence rate of perinatal depression), or Uniform distribution (willingness to accept CBT).

We calculated the Incremental Cost-Effectiveness Ratio (ICER) based on the combined costs and effectiveness derived from the sensitivity analyses. If there is a trade-off between cost and effectiveness, a threshold is needed; that is, how much society is willing to pay for additional health. We set the level of society's willingness-to-pay (WTP) at 194,780 HKD (about £20,000) per QALY, which is the lower threshold set by NICE [9]. In addition, we generated tornado diagrams, incremental cost-effectiveness scatter plots, and cost-effectiveness acceptability curves to assess the likelihood of the intervention being cost-effective.

In the baseline analysis (Table 2), compared with TAU alone, completing the Whooley questionnaire and completing CBT resulted in an additional 0.02 QALY, indicating improved health outcomes for patients who underwent screening. At the end of the perinatal period, the average cost per patient per year in the TAU alone cohort was 8,381.12 HKD with a mean QALY of 0.780, compared to an average cost of 9,281.38 HKD and a mean QALY of 0.800 in the Whooley combined with CBT or TAU arm.

Table 2

Incremental cost-effectiveness of the Whooley combined with TAU or CBT
Treatment Strategy	Cost (HKD)	QALYs	Incremental		ICER (HKD/QALY)
Treatment Strategy	Cost (HKD)	QALYs	Cost (HKD)	QALYs	ICER (HKD/QALY)
TAU	8381.12	0.78	-	-	-
Whooley combined with TAU or CBT	9281.38	0.80	900.26	0.02	45013

The tornado diagram (Fig. 2) illustrates the results of the deterministic sensitivity analysis, indicating the robustness of our findings. The study found that the medication costs for both the CBT and TAU arms, the consultation costs for the TAU arm, and the QALYs associated with depression over a patient's perinatal period had the most impact on the ICER. These ranges provided for each parameter reflect the upper and lower bounds used in the sensitivity analysis to assess the stability of the ICER. The combination of Whooley screening with CBT or TAU may result in improved patient outcomes, but the exact cost-effectiveness comparison requires further probabilistic sensitivity analyses.

The results of the probabilistic sensitivity analysis are shown in Figs. 3 and 4. Figure 3 illustrates the impact of parameter uncertainty on ICER, displaying a scatter plot depicting the outcomes of 10,000 Monte Carlo simulations. The scatter plots show the difference in costs and QALYs per patient per simulation between screening and offering CBT compared to TAU only. The results show that 27.57% of simulations are located in the lower right quadrant region of the scatterplot, indicating the new strategy is dominant compared to TAU alone. About 72.43% of the simulations are in the upper right quadrant, which means a trade-off between cost and effectiveness in health utility. About 56.84% of these simulations were below the threshold of 194,780 HKD for incremental health. All simulations lie on the right side of the y-axis, so the certainty of improved health outcomes with Whooley combined with CBT or TAU is high.

Figure 4 illustrates the probability that Whooley combined with CBT or TAU is cost-effective at various values of WTP. For the zero threshold, the probability of TAU alone being cost-effective is 72.43%, while the probability of Whooley combined with CBT or TAU is 27.57%. At a WTP of about 70,000 HKD, the likelihood of the two treatments being cost-effective is essentially equal. The results suggest that if the WTP is set to 194,780 HKD per QALY, there is an about 84% chance that Whooley combined with CBT or TAU is more cost-effective than TAU alone.

Principal Findings

Perinatal depression is a significant social and public health issue. In this study, we develop a decision tree model to estimate the cost-effectiveness of screening for perinatal depression in Hong Kong using the Whooley questionnaire combined with offering treatment CBT. Compared with TAU alone, the new combination strategy is more likely to improve the health outcomes of individuals. Based on the results, the new strategy is estimated to provide an additional 0.02 QALYs. Additionally, if the WTP 194,780 HKD for each QALY gained is accepted, then the new method has a high probability of being cost-effective compared to TAU alone.

Considering the significant burden that perinatal depression places on the economy, several studies have explored the cost-effectiveness of screening and treatment for this disease. Heslin et al. [67] examined the cost-effectiveness of different screening tools for detecting perinatal depression. They considered tools for perinatal depression screening including the Whooley questionnaire and Edinburgh Postnatal Depression Scale (EPDS). The results showed that the Whooley questionnaire was more cost-effective than no screening and saved more health resources than the EPDS. Yildirim et al. [68] conducted a study to determine the cost-effectiveness of screening for depression in the adult population. They also utilized the Whooley questionnaire, the EPDS, and a combination of the two. They even compared the effect of screening frequency on outcomes. According to the results, for individuals, the annual Whooley screening strategy had the highest ICER.

A previous study [69] assessed the cost-effectiveness of CBT as an adjunct to pharmacotherapy for treatment-resistant depression. The results showed the probability of CBT-based care being cost-effective under the WTP specified by NICE was 74%. Other studies that [70] compared the effectiveness of FCBT with Internet-based CBT (ICBT) for patients with depression suggested internet-based one was the most effective in terms of economic cost and time. Although both approaches were effective in reducing depression symptoms, the study has demonstrated that appropriate screening and timely treatment of depression improves patients' health. Besides, under a reasonable WTP threshold, the possibility that Whooley screening and CBT are cost-effective is also very high, which is generally consistent with the results of our study [62, 63, 70].

Implications

Conducting health economics evaluations for integrating screening and treatment of perinatal depression is clinically important. Through screening, perinatal depression can be recognized at an early stage and intervened promptly, preventing the escalation of depressive symptoms. CBT can be effective in alleviating depressive symptoms in Hong Kong mothers, providing them with practical coping strategies to achieve improved mood [71]. Our study suggests that screening using the Whooley questionnaire and offering CBT as treatment can be cost-effective for reducing the burden of perinatal depression [72]. Subsequent investigations should be conducted to further establish the cost-effectiveness of this strategy.

Currently, most health economics studies focus on drug treatment, and research on screening or non-pharmacological therapies is scarce. Some studies [29, 31, 73] have confirmed that screening can identify perinatal depression at an early stage. Several RCTs [6, 74] have demonstrated the effectiveness of CBT during pregnancy and up to one year postpartum. Our study combines the screening and treatment processes and applies an economic model based on the Hong Kong population to inform local health policymakers. These findings can provide insights into clinical guidelines to enhance the efficient utilization of healthcare resources. With further evidence, policymakers in other regions may consider scaling this strategy and incorporating it into standard perinatal care.

Strengths and Limitations

Several strengths exist in this study. First, we addressed an important theme by assessing the economic benefits of screening for and treating perinatal depression. Despite the availability of several accessible screening tools and treatments, perinatal depression is acknowledged as a persistent public health concern with a rising prevalence. We utilized a decision tree model to simulate mothers' choices enabling our findings to accurately represent the current situation of perinatal depression in Hong Kong, which is valuable for public health officials and healthcare providers. In addition, these data can be generalized to populations in other regions and have the remarkable potential to optimize existing treatment strategies. Finally, we found that the Whooley questionnaire combined with offering CBT has a potential cost-benefit value compared to TAU alone.

This study also has some limitations. First, we only used secondary data with estimates rather than direct measurements. This may affect the accuracy of the findings and thus may not fully reflect the picture of perinatal depression treatment in Hong Kong. Reliance on secondary data may introduce a degree of uncertainty or bias. Additionally, we only measured direct health costs and no other indirect costs of the final status in the model. Indirect costs typically represent a significant portion of total healthcare-related costs, and this exclusion limits the comprehensiveness of our economic evaluation and may underestimate the true economic burden.

To the best of our knowledge, this is the first health economics study to combine screening and treatment for perinatal depression based on the Hong Kong population. We evaluated the cost-utility of the Whooley questionnaire integrating CBT or TAU compared to TAU alone based on results from multiple original research and meta-analyses. We incorporated various model parameters into our model, unveiling the significant potential of this new treatment strategy. The new treatment strategy can provide more benefits for perinatal mothers without incurring excessive costs beyond the suggested WTP, making it a promising strategy for the standard perinatal care process.

CBT

Cognitive Behavioral Therapy

EPDS

Edinburgh Postnatal Depression Scale

FCBT

Face-to-Face CBT

ICBT

Internet-based CBT

ICER

Incremental Cost-Effectiveness Ratio

NICE

National Institute for Health and Care Excellence

QALY(s)

Quality-Adjusted Life Years

RCT

Randomized controlled trials

TAU

Treatment as Usual

WTP

Willingness-to-pay

Ethics approval and consent to participate: Not applicable.

Consent for publication: Not applicable.

Availability of data and materials: All related data generated or analyzed during this study are included in this published article [and its supplementary information files]. Further information regarding the data can be obtained by contacting the corresponding authors.

Competing interests: The authors declare that they have no competing interests.

Funding: This work was supported by an internal grant to Robert David Smith of the Faculty of Health Sciences, University of Macau.

Authors' contributions: Concept and design: Bohan Wang, Robert David Smith. Acquisition, analysis, or interpretation of data: Bohan Wang, Shuyuan Shen, Robert David Smith. Drafting of the manuscript: Bohan Wang, Shuyuan Shen, Robert David Smith. Critical revision of the manuscript for important intellectual content: Bohan Wang, Shuyuan Shen, Robert David Smith. Statistical analysis: Bohan Wang. Supervision: Robert David Smith.

Acknowledgments: Not applicable.

Authors’ information:
Bohan Wang;
Faculty of Health Sciences, University of Macau, Taipa, Macau, China
Address: Block E12, University of Macau, Avenida Avenida, Taipa, Macau, China
Email: [email protected]

Shuyuan Shen;
Faculty of Health Sciences, University of Macau, Taipa, Macau, China
Address: Block E12, University of Macau, Avenida Avenida, Taipa, Macau, China
Email: [email protected]

Robert David Smith;
Faculty of Health Sciences, University of Macau, Taipa, Macau, China
Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macau, China
Address: Block E12, University of Macau, Avenida Avenida, Taipa, Macau, China
Email: [email protected]

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A Cost-Utility Analysis of Screening and Cognitive Behavioral Therapy compared to usual care for Perinatal Depression

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Abstract

Figures

1 Introduction

2 Methods

2.1.1 Transition Probabilities

2.1.2 Incidence Rate of Perinatal Depression

2.1.3 Specificity and Sensitivity of Whooley Questionnaire (True-Negative and True-Positive)

2.1.4 Willingness to Accept CBT

2.1.5 Measurement of Costs

2.1.6 Health Utility

3 Results

4 Discussion

5 Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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Version 1