Cost-Effectiveness and Patient Choice of PTSD Therapy

Participation in a treatment begins with choice of treatment. In evaluating efficacy or effectiveness, though, we often do not pay attention to this act of choosing, nor do we give much thought to whether choice in and of itself may lead to lower economic costs or improved patient outcomes. Nowhere is choice more important than for mental health treatments. Mental disorders often have causes both inside and outside the body. Individuals may have strong opinions about treatments that target biology, cognition, or behavior. Because of this, they may experience some relief of their distress when they receive the treatment that they prefer. They may also adhere to treatment better and be more willing to persist with therapy during setbacks.

The gold standard in research, the randomized clinical trial, ignores these benefits of choice. In fact, by its nature, the traditional randomized clinical trial prohibits choice. An alternative to this approach is a doubly randomized preference trial. This type of trial randomizes participants to either their choice of treatment or further randomization to an assigned treatment. The benefit of this design is that it separates the effect of choice from the effect of treatment on outcome.

My colleagues and I evaluated cost-effectiveness in a prospective doubly randomized choice trial of 2 treatments for posttraumatic stress disorder (PTSD). Specifically, we studied the incremental cost of obtaining a unit health effect in quality-adjusted life-years. We chose to study the effect of choice, a psychological therapy (prolonged exposure), and a pharmacotherapy (sertraline). We administered each treatment for 10 weeks and tracked patients for 1 year. We collected information on direct and indirect medical costs as well as effectiveness. Results suggest that giving patients a choice between prolonged exposure therapy and sertraline is a cost-effective shared decision-making strategy. In the absence of choice, prolonged exposure is more cost-effective than sertraline.

The traditional restriction of choice in our research methods has affected the dialogue in evidence-based practice. Our concern has revolved around the question, “Which treatment has greater efficacy or effectiveness?” This question drives systematic reviews, meta-analyses, cost-effectiveness models, and, ultimately, guidelines of care. Yet, effective treatments are not discovered through rigid adherence to this narrow scientific question. They arise in the context of decisions made by patients about which treatment they choose to pursue. The notion of what constitutes an effective treatment may depend in part on patient preferences. Giving patients a choice of either sertraline or prolonged exposure therapy for chronic PTSD may yield a benefit of its own. In general, we need to further explore whether shared decision-making should play a greater role in mental health guidelines.

Financial disclosure:Dr Doctor is a consultant for Baxter Biosciences and Precision Health Economics and has received grant/research support from Baxter Biosciences.