Costs and cost effectiveness of a mental health intervention for war affected young persons: decision analysis based on a randomized controlled trial.
BACKGROUND One billion children live in war affected regions of the world. We conducted the first cost effectiveness analysis of an intervention for war affected youth in sub Saharan Africa, as well as a broader cost analysis. METHODS The Youth Readiness Intervention (YRI) is a behavioural treatment for reducing functional impairment associated with psychological distress among war affected young persons. A randomized controlled trial was conducted in Freetown, Sierra Leone, from July 2012 to July 2013. Participants (n 436, aged 15 24) were randomized to YRI (n 222) or care as usual (n 214) Functional impairment was indexed by the World Health Organization Disability Assessment Scale; scores were converted to quality adjusted life years (QALYs) An 'ingredients approach' estimated financial and economic costs, assuming a societal perspective. Incremental cost effectiveness ratios (ICERs) were also expressed in terms of gains across dimensions of mental health and schooling. Secondary analyses explored whether intervention effects were largest among those worst off (upper quartile) at baseline. RESULTS Retention at 6 month follow up was 85% (n 371) The estimated economic cost of the intervention was $104 per participant. Functional impairment was lower among YRI recipients, compared with controls, following the intervention but not at 6 month follow up, and yielded an ICER of $7260 per QALY gained. At 8 month follow up, teachers' interviews indicated that YRI recipients observed higher school enrolment [P 0.001, odds ratio (OR) 8.9] denoting a cost of $431 per additional school year gained, as well as better school attendance (P 0.007, OR 34.9) and performance (P 0.03, effect size 1.31) Secondary analyses indicated that the intervention was cost effective among those worst off at baseline, yielding an ICER of $3564 per QALY gained. CONCLUSIONS The YRI is not cost effective at a willingness to pay threshold of three times average gross domestic product per capita. However, results indicate that the YRI translated into a range of benefits, such as improved school enrolment, not captured by cost effectiveness analysis. We also outline areas for modification to improve cost effectiveness in future trials. TRIAL REGISTRATION clinicaltrials.gov Identifier: RPCGA YRI 21003.
Health policy and planning