Behavior Modification Significantly More Cost Effective vs. Pharmacotherapy for ADHD

By John Henry Dreyfuss, MDalert.com staff.

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  • Beginning treatment of attention deficit hyperactivity disorder (ADHD) with a low-dose/intensity regimen of behavior modification was found to be less costly for a school year of treatment than beginning treatment with a low dose of stimulant medication.
  • Behavior modification therapy (large-group parent training) cost $961 per school year in 2013 U.S. dollars compared with $1,669 for pharmacologic therapy.
  • Outcome data found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication.

Beginning treatment of attention deficit hyperactivity disorder (ADHD) with a low-dose/intensity regimen of behavior modification was found to be less costly for a school year of treatment than beginning treatment with a low dose of stimulant medication, according to a cost-effectiveness study published recently in the Journal of Clinical Child and Adolescent Psychology.

 

Figure 1. The subtypes of attention deficit hyperactivity disorder.
 Behavior modification therapy (large-group parent training) cost $961 per school year in 2013 U.S. dollars compared with $1,669 for pharmacologic therapy. The finding persisted irrespective of whether the initial treatment with behavioral therapy was intensified or if the other modality was added.

“Outcome data from the parent study (Pelham et al., 201X) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication,” the authors noted. “Combined with the present analyses, these findings suggest that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.”

 

Figure 2. A molecular model of methylphenidate, a stimulant
used commonly in the treatment of ADHD.

The Analysis

The authors performed a cost analysis of the behavioral, pharmacologic, and combined interventions for ADHD. The therapies were evaluated in a sequential, multiple assignment, randomized, and adaptive trial investigating the sequencing and enhancement of treatment (N=146; 76% male; 80% Caucasian).

The researchers evaluated quantity of resources expended on each child's treatment based on records that listed the type, date, location, persons present, and duration of all services provided. The variables included amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline.

“Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration,” the authors noted.

Pharmacologic Therapy Only

A Canadian cost-effectiveness study of pharmacologic therapy only compared the use of guanfacine extended-release (GXR) monotherapy versus GXR plus a stimulant. The study, published in The Journal of Managed Care and Specialty Pharmacy, reports that GXR plus an adjunctive stimulant conferred improved quality of life adjusted year (QALY; 0.655 vs. 0.627) at a slightly higher cost ($CA1,617 and $CA949).

 

Figure 3. Guanfacine tablets.

“From a societal perspective, GXR + stimulant and stimulant alone were associated with total costs of $CA3,915 and $CA3,582, respectively (difference of $CA334), which resulted in an [incremental cost-effectiveness ratio] of $CA11,845/QALY,” the authors noted.

Over a 1-year time horizon, GXR + stimulant was a cost-effective strategy in 100% of the simulations computed by the researchers. “Probabilistic sensitivity analysis (PSA) of GXR + stimulant showed that it remains a cost-effective strategy in 100 % of the simulations from both perspectives in numerous PSA and one-way sensitivity analyses, relative to a willingness to pay threshold of $50,000/QALY,” the authors explained.

“This economic evaluation demonstrates that GXR + stimulant is cost-effective compared to stimulant alone in the treatment of children and adolescents with ADHD in Canada. This economic evaluation demonstrates that GXR + stimulant is cost-effective compared to stimulant alone in the treatment of children and adolescents with ADHD in Canada,” they concluded.


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