A stepped care programme for depressive or anxiety disorders offers good value for money.

ED FROM Van’t Veer-Tazelaar P, Smit F, van Hout H, et al. Cost-effectiveness of a stepped care intervention to prevent depression and anxiety in late life: randomised trial. Br J Psychiatry 2010;196:319–25. Correspondence to: Petronella van’t Veer-Tazelaar, Department of General Practice, VU Medical Centre, Institute for Research in Extramural Medicine, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands; [email protected] Source of funding: The Netherlands Health Research Council. Additional references are published online only at http://ebmh.bmj.com Depression and anxiety disorder have a high prevalence in older people and signifi cantly impact on their well-being and functioning. Given the limited capacity of adequate treatments for this clinical population and considerable obstacles in case recognition, diagnosis and provision of treatment, health professionals have long recognised the need for prevention programmes that are clinical and cost-effective. In a recent randomised controlled trial, van’t Veer-Tazelaar and colleagues demonstrated the effectiveness of a stepped care prevention programme for depression and anxiety disorders in older people at high risk of developing these conditions.1 In this paper, they present the results of a comprehensive economic evaluation that was conducted alongside the trial. They demonstrate that the probability the prevention programme is cost-effective exceeds 50% at willingness to pay thresholds of at least €5000 for their primary unit of health outcome, a disorder-free year gained. The study design, data collection methods and reporting and interpretation of study results meet the requirements for rigorous health economic evaluation currently applied by health economists. However, the paper raises a number of pertinent issues for clinicians and decision-makers as they consider its implications for practice. First, the health outcome used by the authors, the disorder-free year gained, was based on patients’ risk of developing depression or anxiety rather than the quality-adjusted life year metric,2 which is more useful for comparative purposes and in line with methodological guidance.3 As a result, decision-makers may struggle to determine whether a probability of cost-effectiveness of 57% at a willingness to pay threshold of €5000 per disorderfree year gained represents good value for money. Second, the economic evaluation follows the time horizon of the randomised controlled trial, namely the period between randomisation and 12-month followup. Restricting the evaluation to this time horizon may have underestimated the long-term cost-effectiveness of the programme, since the additional participants in the intervention group without depression or anxiety are likely to continue to generate disorder-free years beyond 12 months. Third, the stepped-care prevention programme consisted of four sequential steps: watchful waiting, bibliotherapy, problem-solving treatment and antidepressant medication. Although the authors note that the costs attributable to the prevention programme might be reduced by re-ordering the steps, the costs and consequences of its component parts are likely to be synergistic rather than independent. Further trial-based economic evaluations will be required to assess the cost-effectiveness of restructured stepped-care prevention programmes.