Cost Effectiveness of ADHD Treatments

In the previous post on the economic impact of ADHD, we examined some of the eye-opening numbers attached to the disorder of ADHD and its impact on society. We reviewed 4-5 publications on the subject, most of which attached an annual price tag of several thousand dollars to the direct and indirect costs of the disorder on individuals with ADHD and their families. These factors included loss of productivity at work (which can be up to almost a full month of the year less than non-ADHD counterparts), medical expenses from the disorder itself, as well as from the increase in risk-taking behaviors of ADHD patients, additional educational expenses, loss of work time for family members, and the increased cost of treatment for substance abuse (which is also much higher in ADHD individuals).

It is important to take these numbers and figures with a grain of salt, and see them more as projections as opposed to actual hard, concrete figures. However, they should begin to give us at least a ballpark estimate of the economic impact that ADHD has on our society. The natural question which should flow from this information is: what is the actual cost of treating ADHD? While the treatment options for ADHD vary immensely from individual to individual and treatment to treatment, a study by Jensen and coworkers has sought to investigate the approximate cost-effectiveness of different ADHD treatments. A summary of this study can be found here. I will highlight some of the key points from the article:

• Cost-effectiveness for ADHD treatment was studied in four different areas: medication treatment, behavioral management treatment, a combined medication/behavioral treatment, and community care-based treatment (this last one would include things like juvenile justice programs, community mental health services, etc) . These data were based off of an original 1999 study on children with ADHD called the MTA Cooperative Group.
• Treatment "effectiveness" was determined by the ability of a particular treatment to bring a child's behavior to a "normal" level. An outcome of "normal" was determined by using a cutoff score determined by a special psychological scale called the SNAP scale, which assigns numbers to behavioral improvements in multiple categories, and is determined by parents, teachers and clinicians. Although somewhat subjective in nature, this scale has been a good indicator of tracking improvements with regards to the disorder of ADHD.
• Different scenarios of ADHD with regards to comorbid (co-existing) disorders were also analyzed. These included both internalizing comorbid disorders (anxiety and depression), externalizing comorbid disorders (which include conduct disorders or oppositional behaviors), as well as a combination of both types of comorbid disorders.
• Costs were determined by average consulting fees of psychiatrists, psychologists and behavioral therapists from the American Medical Association Socioeconomic monitoring system surveys, the approximate costs of prescription drugs based on wholesale prices and common markup values (often around 40%), and wages of behavioral support staffs.
• Out of the different treatment methods available, medication alone provided the most bang for the buck, as far as the most cost-effective measures go. Behavioral therapy was found to be exceedingly costly in terms of its relative effectiveness, and in some cases, actually limited some of the improvements in the overall symptoms. Thus, from a strictly economic standpoint, medication treatment appears to win out as the most cost-effective treatment for ADHD.
• Interestingly, it appears that for children with more internalizing ADHD comorbid symptoms (anxiety and depression), the behavioral treatments were not only more costly, but reduced the overall effectiveness of the medication treatment option, when compared to the medication option alone. This was a bit surprising, and suggests, that behavioral therapy should be considered more for externalizing symptoms (such as oppositional behavior or conduct problems) than for internalizing ones.
• This report was not meant to knock the effectiveness of behavioral treatment for ADHD, it just sought to investigate the cost-effectiveness (or lack thereof) of this type of treatment. However, if cost is not a factor, a combined medication/behavioral treatment program led to much higher rates of "normalizing" childhood behaviors, especially in children who exhibited both internalizing and externalizing comorbid disorders. In other words, for children who have ADHD, anxiety or depression, as well as some type of oppositional behavior, combining medication with therapy can be much more effective than treatment via either medications or therapy alone. However, based on a cost-effectiveness model, for those on a tight budget or with limited resources, the medication treatment option still wins hands-down.
• It is also important to note that community-based care programs, while largely inexpensive, often, unfortunately, have little effectiveness in treating ADHD with or without these side disorders, even though medication managements and behavioral measures are often utilized. This suggests the importance of specialization of professionals outside of basic community resources for dealing with and treating these disorders, which, unfortunately, often carries a heftier price tag. However, the approximate increase in costs of medication management alone (including the cost of a qualified diagnosing professional outside of the typical "community" environment), was relatively small in comparison to the community care model. This again, supports the evidence of the cost-effectiveness of a predominantly medication-based treatment.
• The ineffectiveness of community-based care was explained in part by the relatively lower levels of dosing for medications as well as less follow up (community care physicians often followed up only twice per year in the study, while the individuals on the non-community care based medication treatment plan often got monthly visits).

I realize that some of these findings are confusing to interpret. There were sections of the paper which were difficult to follow at times, but I would just like to hammer home a few personal points with regards to my thoughts on the article:

• Given the pinch most of us are feeling with the economic situation, we want to seek out the best treatments possible for the dollar. Based on this study, it appears that treatment with medication is by far the most cost-effective option.
• If money (or insurance) is less of a problem, there are advantages to utilizing behavioral treatment methods for ADHD. However, based on the findings of the above study, it appears that behavioral treatment on its own is still largely cost-ineffective.
• The one exception to the above point is if a child exhibits both internalizing (anxiety, depression) symptoms and externalizing symptoms (oppositional behaviors or conduct issues) along with his or her ADHD symptoms. It appears that, based on the results of the study listed above, that a combined medication and therapy treatment may be advantageous, although the price still jumps once behavioral management treatments are introduced.
• I realize that the idea of "drugging" our children is inherently wrong in the minds of most individuals. While I personally have a natural bias against this treatment method, I have written extensively about the relative safety and lack of risk factors for most ADHD medications out there today. Given the fact that many of us are feeling the pinch economically, medication treatment is often the only cost-effective option to most people, and this study indicates how cost-effective this treatment method really is.
• By no means is this post meant to downplay the vital role of community-based programs and treatment options out there, for a number of individuals, these programs have been extremely beneficial. Additionally, I know that a number of children exhibit wonderful behvioral changes with regards to their ADHD and related disorders. Nevertheless, the purpose of this review was to simply investigate the cost-effectiveness of these treatment options, and, on the whole, these resources often provide less bang-for-the-buck than medication treatments.
• Finally, I acknowledge that this is just one major study, and that to attach an unquestionable certainty to these findings would be irresponsible. However, we should note that, from the previous post, that the cost of untreated ADHD poses as an enormous economic threat to our society. As a result, all of the measures addressed in the passage above offer at least some degree of advantage over leaving ADHD and its comorbid disorders untreated.

If I can find enough quality studies on the topic, I may post further discussions on the cost effectiveness of different specific medications for ADHD in the near future. In the meantime, we will be returning to more hard-science based articles for the next several posts.

The Economic Impact of ADHD

Since the economy seems to be on everyone's mind these days, I wanted to shift gears for a couple of posts and briefly discuss some of the economic impacts of ADHD. In this post, we will begin by reviewing some articles on the approximate cost that untreated ADHD bears on society. In the next one, we will review a paper on what (in general) are the most cost-effective treatment options for ADHD.

Direct and indirect costs associated with ADHD. There was an excellent review done by Bernfort and colleagues on ADHD from a socio-economic perspective, which investigated the effects of costs such as increased educational expenses, costs of addressing drug and substance abuse (which is higher in ADHD individuals than the general population), increased traffic accidents, employment costs (such as loss of productivity), health care costs (which cover both prescription drugs as well as therapy, as well as increased medical costs from high-risk behavior, which is also more common in individuals with ADHD), as well as a few others. The importance of this study was to shed light on some of the far-reaching implications of the ADHD and the surmounting costs associated with them.

Another review article by Pelham and coworkers attempted to put a price tag on these different factors and behaviors. The review, which investigates costs associated with pediatric and adolescent ADHD, and factors in issues such as education (and special educational needs), loss of work to parents of ADHD children, impacts on the juvenile justice system as well as health-care costs, placed the overall cost per individual with ADHD to be almost $15,000 annually! While I personally view this number as being a bit high, I believe that the sheer magnitude of this number is extremely telling, and an important indicator for the need for proper treatment for children and young adults with the disorder.

We have spent a number of pages investigating the high heritability of the disorder by investigating the genetic components of ADHD. Given this fact, family studies and the economic impact of the disorder of ADHD on families should be especially relevant. From a study (note that this was done by Eli Lilly, so please consider the source) on medical claims found a 2 to 3-fold higher cost of claims and payouts to family members of ADHD. These number suggest the significant burdens that can be placed on both family members and their health care providers surrounding their relationship with ADHD individuals. Keep in mind that the genetic component of ADHD is often believed to be somewhere around 75% (and some studies place it as high as 90%), so the likelihood of multiple cases of ADHD in a single family is also high. Not surprisingly, the financial burden is another facet of the disorder which can act as another source of stress on parents and other family members of ADHD children, especially during more difficult economic times.

Finally, claims data from individuals with ADHD and their family members was obtained from a single large company in the US, and an attempt was made to extrapolate the data to the American population as a whole (which is a big if, but may be at least indicative of the whole population, if the makeup of this company is even close to being representative of the US population as a whole). Taking into account factors such as health care and work loss costs involved with the individuals with ADHD and their families, this study estimated a total excess (meaning above the average non-ADHD person) cost to be over 30 billion dollars a year. Breaking this down amongst the individuals with the disorder (which, using a relatively conservative estimate of 5% of the US population, which would put around 15 million individuals as having the disorder), this would amount to around $2,000 per person. This falls somewhere in between the numbers tossed around by some of the other studies.

Again, keep in mind that this data is extrapolated from a small portion of the American population, which, statistically, is often a dangerous thing to do. However, just the sheer magnitude of these numbers, especially when we begin to see some degree of numerical overlap between economic estimates from different studies on the costs associated with treating or dealing with the disorder of ADHD should be eye-opening, even if there is still a fair amount of ambiguity involved among some of these figures. Since most of these studies place the direct and indirect economic impacts of the disorder to be in the thousands (and in some cases 10 thousands) per person, we can see the importance of treating the disorder and its potential economic impacts on society as a whole. In the next post, we will investigate the cost-effectiveness of different measures in treating ADHD (along with some of the common comorbid or co-existing disorders).