Aspects of cost-effectiveness and feasibility of implementations for care of depressed persons in primary care - internet-based treatment and care manager organisation

Background: Depression is a major source of human suffering and a growing challenge for societies worldwide. The lion’s share of depressed persons in Sweden are diagnosed and treated in primary care. There is an urgent need for new ways of treating and cooperating within and between care levels. Internet-mediated cognitive behavioural therapy (ICBT) and collaborative care with a care manager (CCCM) are two examples of implementations intended to meet the demands of reinforced continuity, accessibility and coordination in treatment and care of patients with mild to moderate depression. Aim: The aim of this thesis was to evaluate ICBT and CCCM in the Swedish primary care setting from the perspectives of cost-effectiveness and feasibility including the experience of patients and staff. Papers I–II: ICBT was compared to treatment as usual (TAU) in a cost-effectiveness analysis made from both health care and societal perspectives. The patient experience of ICBT was studied by means of focus groups and interviews. ICBT seemed to be an alternative as effective and cost-effective as TAU from both from health-care and societal perspectives. The largest cost in both groups was productivity loss related to sick leave. ICBT was shown to be an attractive treatment for some patients, but not for all. The freedom of ICBT was appreciated but the responsibility placed on the patient was considerable. Papers III–IV: CCCM was compared to care as usual (CAU) in a cost-effectiveness analysis from both health-care and societal perspectives. Questionnaires including closed and open questions were used to study the experiences of primary care centre (PCC) directors and clinicians. CCCM was shown to be cost-effective compared to CAU from both health-care and societal perspectives. CCCM was also perceived to be effective and positive by both directors and clinicians. Facilitators for CCCM were support from colleagues and directors, cooperative skills and positive attitudes of care managers and clinicians. Barriers were high workload, shortage of staff and extensive requirements and demands from health-care management. Conclusion: ICBT seems to be an acceptable alternative to TAU in terms of patient experience and cost-effectiveness. CCCM is highly cost-effective compared to CAU and both PCC clinicians and directors are generally positive to implementing – and working within – CCCM