Archives of Psychiatry and Psychotherapy, 2014; 4 : 57–64

Cost-effectiveness analysis of psychotherapy in treatment of essential hypertension in primary care Zhanna Kalmatayeva, Ainur Zholamanova Summary Aim of the study. To estimate expediency of psychotherapy in patients with essential hypertension from a clinical and economic perspective. Place and duration of study. Clinical material was collected from September 2011 to February 2012 in Polyclinic no. 12, Almaty and the Central City’s Polyclinic, Kaskelen. Method. 75 patients with identified psychosomatic disorders (37 male, 38 female) suffering from hypertension of a first or second degree (from 140/90 to 179/109mmHg) were randomised into two groups (mean age 48.5±3.69 and 47.5±4.2 years). All patients received therapy within the same scheme, but group 1 was additionally treated with psychotherapy. Results. Qualitative improvements were shown on all scales of the “Mini-mult” test for group 1. The control examination of mean blood pressure (BP) at week 14 found a statistically significant difference in final systolic blood pressure (SBP) between the two groups (134.27±3.7 vs. 137.33±3.9, p=0.032), but no such difference in final diastolic blood pressure (DBP) (82.93±5.1 vs. 83.81±4.3, p=0.198). The average cost of the 24-week treatment per person was 47.81USD for group 1 (standard treatment with psychotherapy) and 48.62USD for group 2 (standard treatment). The cost of SBP reduction was 1.98 vs. 2.53USD per 1mmHg for group 1 and 2 respectively and for DBP reduction it was 3.19 vs. 3.73USD per 1mmHg for group 1 and 2 respectively. Blood pressure (BP) reduction was faster in group 1 (7.05 vs. 7.97 weeks). Conclusions. Conservative treatment of hypertension combined with comprehensive psychotherapy leads to better results compared with a conventional conservative treatment scheme, from psychological, clinical and economic points of view, bur results can be different in another country. More trials in different countries with greater numbers of patients are necessary.

hypertension / psychosomatic diseases / psychotherapy / cost-effectiveness analysis adoptive family research methodology / adoption / adoptive family

Introduction According to the WHO Regional Office for Europe database, every year 30,000 new cases of arterial hypertension (AH) are identified in the Republic of Kazakhstan [1]. Kazakhstan national statistical bulletin informs about the prevalence of AH cases at up to 1970.18 per 10,000 people in 2012 [2]. According to various researchers, the prevalence of AH in Kazakhstan varies from 15.2 Zhanna Kalmatayeva, Ainur Zholamanova: School of Public Health, Ministry of Health, Republic of Kazakhstan. Correspondence address: [email protected] Acknowledgements: We are grateful to the physicians in the Polyclinic No. 12, Almaty and the Central City’s Polyclinic, Kaskelen, Republic of Kazakhstan for assistance in the selection of patients to this study. We are also grateful to Dr Zhanna Kalmatayeva, rector of the Kazakhstan School of Public Health at the Ministry of Health, for her valuable advice, methodological consultations and support.

to 27%, with an almost equal level of prevalence in the urban and rural areas, which is comparable with international data [3]. The standard treatment for established hypertension is antihypertensive medications, diet and exercise. The effectiveness of a combined conservative treatment was confirmed in many trials (ABC-GP study [4], STRATHE [5]) [AQ1. Please note references added to the two trials, correct?]. For patients in the prehypertensive blood pressure range, lifestyle changes are the primary intervention, unless the patient has multiple risk factors. As is generally known, in 1950 the American scientist Alexander attributed AH to the “golden seven” psychosomatic diseases [6], which explains the effect of psychotherapy in the treatment of this illness. The positive effect of psychotherapy on high blood pressure has been confirmed in various studies. Psychotherapeutic assistance in Ka-

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Zhanna Kalmatayeva, Ainur Zholamanova

zakhstan is provided at the primary outpatient level, which allowed us to test psychotherapy for the treatment of arterial hypertension. Hypertension has a tremendous impact on the health of the American public. According to the American Heart Association, the total estimated cost of hypertension in 2007 was 66.4 billion USD [7]. From the modern standpoint of health management, the effective organisation of health care takes into account not only the clinical parameters, but also the economic costs. Our objective was to evaluate the appropriateness of psychotherapy in patients with essential arterial hypertension (EAH) from the clinical and economic standpoint. Method The study was a clinical randomised controlled trial (RCT) combined with economic analysis. Seventy-five patients suffering from EAH were selected. The selection criterion was hypertension of a first or second degree (blood pressure (BP) within 140/90 and 179/109mmHg, as specified in the JNC 7 report) lasting at least 6 months [8]. In addition, all patients were tested using the standard psychodiagnostical tests: the Minnesota Multiphasic Personality Inventory (MMPI), the Giessen Complaint Questionnaire and the questionnaire on psychosomatic complaints [AQ2. Please provide references to all three tests]. We excluded patients suffering from secondary arterial hypertension (due to diabetes mellitus, ischemic heart disease, cardiomyopathy, kidney disease, asthma, respiratory disease, cardiac disease [AQ3. Please note “disease” added in both cases, OK?], renal failure, cancer), patients with organic lesions of the central nervous system and those with psychiatric illnesses (schizophrenia, anxiety and phobic disorders, emotive sphere [AQ4. What was meant by “emotive sphere”, was that “emotional disorders”? It is possible to give any examples?]). Patients received recommendations for the normalisation of blood pressure (restricting alcoholic beverages, reducing salty foods, monitoring fluid intake, quitting smoking, observing work and rest periods).

Participants The selected contingent was randomly divided into two groups. The first group (group 1; N=40) were patients receiving antihypertensive therapy and symptomatic psychotherapeutic correction. The second group (group 2; N=35) were patients receiving only antihypertensive therapy. Patients visited every 2 weeks after the first visit, at 4, 6, 8, 10 weeks, etc., to achieve the target blood pressure (