Research questions of the HTA report:

The aims of this investigation are to

– assess the benefit of

(1) crisis intervention programmes/services or

(2) psychosocial interventions

(technology based or not) in outpatient care in comparison with a different non-drug therapy, drug therapy, inpatient treatment, or no therapy / waiting list in adult suicidal patients with unipolar depression with regard to patient-relevant outcomes,

– determine the costs incurred by

(1) crisis intervention programmes/services or

(2) psychosocial interventions

(technology based or not) in outpatient care in comparison with a different non-drug therapy, drug therapy, inpatient treatment, or no therapy / waiting list in adult suicidal patients with unipolar depression (intervention costs),

– assess the cost effectiveness of

(1) crisis intervention programmes/services or

(2) psychosocial interventions in outpatient care (technology based or not) in comparison with another non-drug therapy, drug therapy, inpatient treatment, or no therapy / waiting list in adult suicidal patients with unipolar depression was well as

– review ethical, social, legal, and organizational aspects associated with the medical interventions.

Conclusion of the HTA report (see Chapter 9):

To answer the question submitted to ThemenCheck, “Suicidal crises in unipolar depression: How do non-drug measures impact their management?”, the following interventions were investigated: (1) crisis intervention programmes/services in outpatient care and (2) psychosocial interventions in outpatient care, namely (i) psychotherapeutic strategies for preventing suicide and (ii) suicide preventive follow-up services and contact offers.

Despite this initially broad definition of interventions to be investigated in the outpatient care of adult suicidal patients with unipolar depression, only studies on cognitive behavioural therapy (CBT) were found, all of which focused on suicidality. These studies examined CBTs from the second and third “waves” of behavioural therapy (BT). The second wave of BT originated in the developments of the 1960s and 1970s, where classic BT was for the first time expanded to include cognitive aspects such as thoughts and convictions. In the 1980s, these considerations led to the approach of CBT. In the third wave of BT, the classic cognitive-behavioural concept, which largely focuses on restructuring processes, is expanded by the additional aspects of mindfulness and acceptance of difficult-to-control internal experiences. Additional conceptual differences concern the fundamental attitude and the patient-therapist relationship. CBT is a service already covered by the statutory health insurance.

Four randomized controlled trials (RCTs) of moderate qualitative certainty of results were included. They primarily investigated the patient-relevant outcomes of anxiety, depressive symptoms, hopelessness, posttraumatic stress, suicidal ideation, and (follow-up) suicide attempts, each at the survey time points of 1, 3, 6, 18, and ≥ 18 months.

With regard to the patient-relevant outcomes of suicidal ideation (6 months), suicide attempts (≥ 18 months), depressive symptoms (3, 6, and 18 months), and hopelessness (6 and 18 months), the results revealed an indication of (added) benefit of second-wave CBT in comparison with treatment as usual (TAU).

With regard to the patient-relevant outcome of depressive symptoms, the results revealed a hint of (added) benefit at the survey time point of 1 month for third-wave CBT in comparison with TAU. These results are based on the data from one study. The currently still outstanding results from another study might supplement the results of this health technology assessment (HTA).

For the outcomes of anxiety and posttraumatic stress (each at 3, 6, and 18 months), suicidal ideation (1, 3, and 18 months), depressive symptoms (1 month), and hopelessness (1 month and 3 months), no hint of (added) benefit of second-wave CBT versus TAU was found.

With regard to third-wave CBT, for the outcome of depressive symptoms at the survey time point of 3 months, no hint of (added) benefit of third-wave CBT versus TAU was found. For the outcome of suicidal ideation at the time point of 1 month, no hint of (added) benefit of third-wave CBT versus TAU was found.

For the following outcomes, data on second or third-wave CBT were either unavailable or unusable: all-cause mortality / overall survival, suicide mortality, physical functioning including activities of daily living / everyday functioning, inpatient admission, serious adverse events, discontinuation due to adverse events, health-related quality of life, and health-related social functioning, including occupational and social participation. Concerning second-wave CBT, data were also reported on social problem-solving ability, but they were disregarded due to reporting bias. However, patients in the initially conducted discussions highlighted the patient-relevant outcomes listed above as being particularly relevant.

Therefore, there is clearly a need for further research, particularly high-quality RCTs, in this area.

No studies were found with regard to cost effectiveness, and no conclusion can be drawn on this topic. To generate more evidence in this area as well, future investigations might concurrently collect data on both effectiveness as well as resource use and the costs of the intervention and comparator treatment. The costs listed in the present report are stated as ranges for patients with mild and severe disease courses. They range from EUR188.67 per treatment case for solely drug-based treatment to EUR2684.14 for one-on-one short-term outpatient therapy, and up to EUR15,314.23 for long-term outpatient therapy. However, comparability between the costs of the individual interventions per patient or per patient and treatment case is limited since their separate analyses do not fully reflect the realities of care. Depressive disorders differ widely between individuals in terms of their severity and course; therefore, actual costs might be lower or higher than those presented herein.

Interventions other than CBT, including some low-threshold interventions such as telephone counselling or internet-based services, were also mentioned both in the focus groups and in the literature. Due to a lack of studies, however, it was not possible to compare these interventions to TAU. As already concluded by authors of other reviews, future studies should include such interventions as well and determine their effectiveness at early survey time points in order to ensure rapid treatment in crisis situations.

The analysis of the ethical, social, legal, and organizational aspects has shown that they are highly relevant to the topic and, in particular, have a major impact on access to measures. Due to the complexity and multidimensional nature of the topic, the individual domains cannot and should not be analysed in isolation. Rather, their mutual interactions should be contemplated and discussed, as illustrated in the logical model.

Publisher

Institute for Quality and Efficiency in Health Care (IQWiG)

Topic

Suicidal crises in unipolar depression: How do non-drug interventions impact their management?

HTA No.

HT17-03

Date of project start

14 December 2017

Address of publisher

Authors

• Sabine Fuchs, Department of Health Care Management, Technische Universität (TU) Berlin, Germany
• Elke Berger, Department of Health Care Management, Technische Universität (TU) Berlin, Germany
• Natalie Baier, Department of Health Care Management, Technische Universität (TU) Berlin, Germany
• Reinhard Busse, Department of Health Care Management, Technische Universität (TU) Berlin, Germany

Clinical expert

• Heike Peters, Psychotherapeutic Practice Group Friedenau, Berlin, Germany

External review

• Dimitra Panteli, Department of Health Care Management, Technische Universität (TU) Berlin, Germany

Author of HTA compact: The most important points clearly explained

Sonja Siegert, commissioned by the Department of Health Care Management, Technische Universität (TU) Berlin, Germany

IQWiG coordinated the project and conducted the literature search for the domains “Benefit assessment“ and “Health economic evaluation”.

According to §139b (3) No. 2 of Social Code Book (SGB) V, Statutory Health Insurance, external experts who are involved in the Institute’s research commissions must disclose “all connections to interest groups and contract organizations, particularly in the pharmaceutical and medical devices industries, including details on the type and amount of any remuneration received”. The Institute received the completed Form for disclosure of potential conflicts of interest from each external expert. The information provided was reviewed by a Committee of the Institute specifically established to assess conflicts of interests. The information on conflicts of interest provided by the external experts and external reviewers is presented in Chapter A12 of the full report. No conflicts of interest were detected that could endanger professional independence with regard to the work on the present commission.