Improved identification of people at risk of psychosis: is it value for money?
Authors: Ben Kearns
Journal: The Lancet Psychiatry (2015)

Development of a psychotic illness, including schizophrenia, can be debilitating for the individual, with life expectancy reduced by up to 15 years,1Van Os J Kapur S Schizophrenia.Lancet. 2009; 374: 635-645Summary Full Text Full Text PDF PubMed Scopus (1694) Google Scholar mainly due to an increased occurrence of cardiovascular disease.2Hennekens CH Hennekens AR Hollar D Casey DE Schizophrenia and increased risks of cardiovascular disease.Am Heart J. 2005; 150: 1115-1121Summary Full Text Full Text PDF PubMed Scopus (845) Google Scholar In the past 5 years, clinician preference has moved towards early detection and intervention by assessment of the risks for developing psychoses, with increasing evidence about the effectiveness of early interventions for psychosis.3Stafford MR Jackson H Mayo-Wilson E Morrison AP Kendall T Early interventions to prevent psychosis: systematic review and meta-analysis.BMJ. 2013; 346: f185Crossref PubMed Scopus (339) Google Scholar Primary care can play an important part in the early identification of individuals at risk, because people with a serious mental illness have an estimated average 13–14 consultations with their general practitioner every year.4Mental Health FoundationThe fundamental facts. Mental Health Foundation, London2007http://www.mentalhealth.org.uk/content/assets/PDF/publications/fundamental_facts_2007.pdf?view=StandardGoogle Scholar However, evidence is scarce with respect to the assessment of factors contributing to the effectiveness of improved detection of individuals at high risk of developing psychosis in primary care. Additionally, in an era of restricted health-care budgets, the assessment of cost-effectiveness for this type of intervention is important. Cost-effectiveness assessments attempt to quantify the trade-off between improved outcomes for the individual and increased costs to the health-care system; in other words, does the intervention represent value for money? In The Lancet Psychiatry, Jesus Perez and colleagues5Perez J Jin H Russo DA et al.Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.Lancet Psychiatry. 2015; (published online Aug 19.)DOI: http://dx.doi.org/10.1016/S2215-0366(15)00157-1Google Scholar report both the clinical effectiveness and cost-effectiveness of a theory-based early intervention to improve liaison between primary and secondary care in UK primary care practices. High-intensity and low-intensity liaisons were assessed (26 practices in high-intensity intervention and 28 in low-intensity intervention), as was practice as usual (50 practices). The authors5Perez J Jin H Russo DA et al.Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.Lancet Psychiatry. 2015; (published online Aug 19.)DOI: http://dx.doi.org/10.1016/S2215-0366(15)00157-1Google Scholar report that practices randomly assigned to the high-intensity intervention referred more individuals for first-episode psychosis to the early intervention services than did the other two practice groups (high intensity vs low intensity; incidence rate ratio [IRR] 1·9, 95% CI 1·05–3·4, p=0·04), although for individuals at high risk of psychosis the increase was not significant. As a result, high-intensity practices referred both more true-positive and false-positive cases of psychosis confirmed after assessment. The increased referral of individuals at high risk of psychosis suggests that the high-intensity intervention is clinically effective, but what about its cost-effectiveness? Implementation of the high-intensity liaison intervention was estimated to cost £1459 per practice (low-intensity intervention cost was £14). However, results of the authors' economic evaluation5Perez J Jin H Russo DA et al.Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.Lancet Psychiatry. 2015; (published online Aug 19.)DOI: http://dx.doi.org/10.1016/S2215-0366(15)00157-1Google Scholar suggest that this intervention would pay for itself (be cost-saving), with the total costs per true-positive referral being lowest in the high-intensity practices. Two key drivers are behind these cost-savings: a reduction in the number of late presenters (individuals whose psychosis is not identified early and are costly to treat) and a reduction in the costs of treating individuals at high risk who are treated early. This study also emphasises5Perez J Jin H Russo DA et al.Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.Lancet Psychiatry. 2015; (published online Aug 19.)DOI: http://dx.doi.org/10.1016/S2215-0366(15)00157-1Google Scholar both the importance of health-economic evaluations in psychiatry and the difficulties that can be encountered. Heath-economic evidence can be used to make comparisons in different interventions, such as what offers more value for money; the high intensity intervention described by Perez and colleagues,5Perez J Jin H Russo DA et al.Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.Lancet Psychiatry. 2015; (published online Aug 19.)DOI: http://dx.doi.org/10.1016/S2215-0366(15)00157-1Google Scholar or a cancer drug? These comparisons can in turn be used to inform re-imbursement or commissioning decisions, but a standardised health outcome that can be used to make comparisons is needed. In some countries, a measure of health-related quality of life (HRQoL) can be used.6Uttley L Kearns B Ren S Stevenson M Aripiprazole for the treatment and prevention of acute manic and mixed episodes in bipolar I disorder in children and adolescents: a NICE single technology appraisal.Pharmacoeconomics. 2013; 31: 981-990Crossref PubMed Scopus (6) Google Scholar However, assessment of the HRQoL of individuals with psychosis, and the effect of interventions on this factor, is challenging and needs further research.7Brazier J Is the EQ-5D fit for purpose in mental health?.Brit J Psychiatry. 2010; 197: 348-349Crossref PubMed Scopus (104) Google Scholar It will be useful to see this type of patient-reported outcome measure included in future trials. Perez and colleagues5Perez J Jin H Russo DA et al.Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.Lancet Psychiatry. 2015; (published online Aug 19.)DOI: http://dx.doi.org/10.1016/S2215-0366(15)00157-1Google Scholar also show the important role of health-economic modelling. It is used in their study to include evidence not collected during their trial—notably the development of psychosis in patients at high risk who are not identified and the later costs of treating them. This ability to synthesise a range of evidence sources is a particular strength of health-economic models. Such models have also been used to map out care pathways (eg, for patients with depression8Tosh J Kearns B Brennan A et al.Innovation in health economic modelling of service improvements for longer-term depression: demonstration in a local health community.BMC Health Serv Res. 2013; 13: 150Crossref PubMed Scopus (9) Google Scholar) and assess the potential effect of any service changes on both patient outcomes and costs to the health-care system. Perez and colleagues5Perez J Jin H Russo DA et al.Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trial.Lancet Psychiatry. 2015; (published online Aug 19.)DOI: http://dx.doi.org/10.1016/S2215-0366(15)00157-1Google Scholar have shown the cost-effectiveness of improved liaison between primary and secondary care. The next question to ask is how best to integrate this intervention into the broader care pathway of patients with, or at risk of, psychosis—including pharmacotherapy, psychotherapy, and any follow-up checks (usually by general practioners, but can also be by secondary care services). Such a question would need an ambitious research project, with questions about cost-effectiveness being a key aspect, along with questions about clinical effectiveness and patient involvement to identify the main difficulties. However, these are the types of questions that should be asked to ensure that future research has the best possible effect on patient health and the organisation and delivery of health services. I declare no competing interests. Clinical effectiveness and cost-effectiveness of tailored intensive liaison between primary and secondary care to identify individuals at risk of a first psychotic illness (the LEGs study): a cluster-randomised controlled trialThis intensive intervention to improve liaison between primary and secondary care for people with early signs of psychosis was clinically and cost effective. Full-Text PDF Open Access