Behavioral activation with mindfulness in treating subthreshold depression in primary care: A cost-utility and cost-effectiveness analysis alongside a randomized controlled trial
Abstract
This study aimed to assess the cost-utility and cost-effectiveness of group-based behavioral activation with mindfulness (BAM) versus care as usual (CAU) for treating subthreshold depression in primary care. Adults aged 18 years or older with subthreshold depression were randomized into two arms and were followed up for 12 months. BAM group was provided with eight 2-h weekly treatment by trained allied healthcare workers. CAU group could access to usual medical care but did not receive extra interventions. The health service cost in the past 12 months was self-reported by the participants. Quality-adjusted Life Years (QALYs) and clinical outcome (incidence of major depressive disorder progression) were measured. Willingness-to-pay ratio for cost-utility analysis (CUA) and cost-effectiveness analysis (CEA) was US$50,000 per QALY and US$20,000 per prevented major depression case, respectively. These ratios were used in the cost-effective acceptability curve analyses to estimate the probability of cost-effectiveness of the estimated incremental cost effectiveness ratios (ICER) of BAM versus CAU. A total of 115 and 116 participants were included in the BAM group and CAU respectively. The estimated CUA ICER was US5,979 per QALY and had a probability of 0.93 that BAM was cost-effective when compared to CAU. Furthermore, when compared to CAU, BAM was cost-effective in preventing progression of major depression: the estimated CEA ICER was US$1046 per preventable case of major progression with a probability of 0.99 to be cost-effective. Group-based BAM is considered as a cost-effective alternative treatment for treating subthreshold depression by preventing major depressive disorder.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Integration of mindfulness into mainstream healthcare is lacking due to structural and organizational barriers, not lack of efficacy.
“integration into mainstream healthcare is lacking – not due to lack of efficacy, but rather structural and organizational barriers [24, 25, 28–31].”
From Exploring patient experiences with a mindfulness course in a general practice setting: a qualitative study. (2025) · cites this paper as [30]
Cites
<b>mice</b>: Multivariate Imputation by Chained Equations in<i>R</i>
Buuren, S. V., & Groothuis-Oudshoorn, K. (2011) · Journal of Statistical Software · doi:10.18637/jss.v045.i03 · Cited by 13,870 · see citing works
The PHQ-9: A New Depression Diagnostic and Severity Measure
Kroenke, K., & Spitzer, R. L. (2002) · Psychiatric Annals · doi:10.3928/0048-5713-20020901-06 · Cited by 5,898 · see citing works
Multiple Imputation of Missing Values
Royston, P. (2004) · The Stata Journal: Promoting communications on statistics and Stata · doi:10.1177/1536867x0400400301 · Cited by 2,340 · see citing works
Analysing controlled trials with baseline and follow up measurements
Vickers, A. J., & Altman, D. G. (2001) · BMJ · doi:10.1136/bmj.323.7321.1123 · Cited by 2,116 · see citing works
The economic cost of brain disorders in Europe
Olesen, J., Gustavsson, A., Svensson, M., Wittchen, H., & Jönsson, B. (2012) · European Journal of Neurology · doi:10.1111/j.1468-1331.2011.03590.x · Cited by 1,560 · see citing works
Manca, A., Hawkins, N., & Sculpher, M. J. (2005) · Health Economics · doi:10.1002/hec.944 · Cited by 1,024 · see citing works
Cost‐effectiveness acceptability curves – facts, fallacies and frequently asked questions
Fenwick, E. A. L., OʼBrien, B. J., & Briggs, A. H. (2004) · Health Economics · doi:10.1002/hec.903 · Cited by 946 · see citing works
Ramsey, S. D., Willke, R. J., Glick, H., Reed, S. D., Augustovski, F., Jonsson, B., Briggs, A., & Sullivan, S. D. (2015) · Value in Health · doi:10.1016/j.jval.2015.02.001 · Cited by 811 · see citing works
Kessler, R. C., Zhao, S., Blazer, D. G., & Swartz, M. (1997) · Journal of Affective Disorders · doi:10.1016/s0165-0327(97)00056-6 · Cited by 790 · see citing works
Mindfulness-based cognitive therapy to prevent relapse in recurrent depression.
Kuyken, W., Byford, S., Taylor, R. S., Watkins, E., Holden, E., White, K., Barrett, B., Byng, R., Evans, A., Mullan, E., et al. (2008) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0013786 · Cited by 770 · see citing works
Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold
Grosse, S. D. (2008) · Expert Review of Pharmacoeconomics & Outcomes Research · doi:10.1586/14737167.8.2.165 · Cited by 637 · see citing works
Cuijpers, P., & Smit, F. (2004) · Acta Psychiatrica Scandinavica · doi:10.1111/j.1600-0447.2004.00301.x · Cited by 595 · see citing works
Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., Barrett, B., Farrand, P. A., Gilbody, S., Kuyken, W., et al. (2016) · The Lancet · doi:10.1016/s0140-6736(16)31140-0 · Cited by 595 · see citing works
Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S. (2014) · PLoS ONE · doi:10.1371/journal.pone.0100100 · Cited by 565 · see citing works
Behavioral activation treatments for depression in adults: A meta-analysis and review.
Mazzucchelli, T., Kane, R., & Rees, C. (2009) · Clinical Psychology: Science and Practice · doi:10.1111/j.1468-2850.2009.01178.x · Cited by 438 · see citing works
Prevalence and risk indicators of depression in elderly nursing home patients: the AGED study
Jongenelis, K., Pot, A. M., Eisses, A. M. H., Beekman, A. T. F., Kluiter, H., & Ribbe, M. W. (2004) · Journal of Affective Disorders · doi:10.1016/j.jad.2004.06.001 · Cited by 427 · see citing works
A meta-analysis of randomized trials of behavioural treatment of depression
Ekers, D., Richards, D., & Gilbody, S. (2008) · Psychological Medicine · doi:10.1017/s0033291707001614 · Cited by 400 · see citing works
Yu, N. X., Tam, W., Wong, P. T. K., Lam, T. H., & Stewart, S. M. (2010) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2010.11.002 · Cited by 392 · see citing works
Behavioural activation for depression
Veale, D. (2008) · Advances in Psychiatric Treatment · doi:10.1192/apt.bp.107.004051 · Cited by 282 · see citing works
Economic costs of minor depression: a population-based study
Cuijpers, P., Smit, F., Oostenbrink, J., De Graaf, R., Ten Have, M., & Beekman, A. (2007) · Acta Psychiatrica Scandinavica · doi:10.1111/j.1600-0447.2006.00851.x · Cited by 226 · see citing works
Behavioural activation delivered by the non-specialist: phase II randomised controlled trial
Ekers, D., Richards, D., McMillan, D., Bland, J. M., & Gilbody, S. (2011) · British Journal of Psychiatry · doi:10.1192/bjp.bp.110.079111 · Cited by 217 · see citing works
Assessing the Use of a Feedback Module to Model EQ-5D-5L Health States Values in Hong Kong
Wong, E. L., Ramos-Goñi, J. M., Cheung, A. W. L., Wong, A., & Rivero‐Arias, O. (2017) · Patient · doi:10.1007/s40271-017-0278-0 · Cited by 139 · see citing works
Backenstraß, M., Frank, A., Joest, K., Hingmann, S., Mundt, C., & Kronmüller, K. (2005) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2005.04.007 · Cited by 112 · see citing works
Depression and anxiety among university students in Hong Kong
Li Ka Shing Faculty of Medicine, T. U. O. H. K., Lun, K. W., Chan, C., Ip, P. K., Ma, S. Y., Tsai, W., Wong, C., Wong, C. H., Wong, T., & Yan, D. (2018) · Hong Kong Medical Journal · doi:10.12809/hkmj176915 · Cited by 90 · see citing works
Cost utility of behavioural activation delivered by the non-specialist
Ekers, D., Godfrey, C., Gilbody, S., Parrott, S., Richards, D., Hammond, D., & Hayes, A. M. (2011) · British Journal of Psychiatry · doi:10.1192/bjp.bp.110.090266 · Cited by 62 · see citing works
Wong, S. Y. S., Sun, Y. Y., Chan, A. T. Y., Leung, M. K. W., Chao, D. V. K., Li, C. C. K., Chan, K. K. H., Tang, W. K., Mazzucchelli, T., Au, A. M. L., et al. (2018) · The Annals of Family Medicine · doi:10.1370/afm.2206 · Cited by 60 · see citing works
Self-citationRESAMPLING AND MULTIPLICITY IN COST-EFFECTIVENESS INFERENCE
Obenchain, R. L. (1999) · Journal of Biopharmaceutical Statistics · doi:10.1081/bip-100101196 · Cited by 29 · see citing works
Sedgwick, P. M. (2010) · BMJ · doi:10.1136/bmj.c1825 · Cited by 18 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Economic Evaluations of Mindfulness-Based Interventions: a Systematic Review
Zhang, L., Lopes, S. S., Lavelle, T. A., Jones, K. O., Chen, L., Jindal, M., Zinzow, H. M., & Shi, L. (2022) · Mindfulness · doi:10.1007/s12671-022-01960-1 · Cited by 45 · see citing works
Cerón, S. C., Lokkerbol, J., Moreno-Peral, P., Wijnen, B. F. M., Fernández, A., Mendive, J. M., Smit, F., & Bellón, J. Á. (2021) · Clinical Psychology Review · doi:10.1016/j.cpr.2021.102064 · Cited by 20 · see citing works
Riley, T. D., Roy, S., Parascando, J. A., Wile, K., LaGamma, C., Dong, H., & Zgierska, A. E. (2022) · Journal of Integrative and Complementary Medicine · doi:10.1089/jicm.2021.0415 · Cited by 18 · see citing works
“17,18 Disenfranchised patients in rural 19 and minority 20,21 communities may face particular challenges in accessing these cost-effective 22–24 interventions.”
Mutyambizi-Mafunda, V., MYERS, B. J., Sorsdahl, K. R., Chanakira, E., Lund, C., & Cleary, S. (2022) · Health Policy and Planning · doi:10.1093/heapol/czac069 · Cited by 14 · see citing works
“Nine of the 18 studies that stated the perspective reported both provider and societal perspectives (Nadkarni et al., 2016; 2017; 2019; Patel et al., 2017; Weobong et al., 2017; Dwommoh et al., 2018; Fuhr et al., 2019; Sikander et al., 2019; Sun et al., 2021).”
BackgroundMethodInfluentialAlhusseini, N. K., Lin, T. K., Werner, K., Lin, G., Altwaijri, Y. A., Baattaiah, B. A., Bruckner, T. A., AlAhmed, R. S., Alkabbani, A. G., Alsukait, R. F., et al. (2025) · BMC Public Health · doi:10.1186/s12889-025-22207-3 · Cited by 5 · see citing works
“Two studies also noted cost-effectiveness despite finding no difference in improving QALY between intervention and control trials, with intervention durations of 6 and 8 weeks [39, 40].”
Sanabria‐Mazo, J. P., D’Amico, F., Cardeñosa, E., Ferrer, M., Edo, S., Borràs, X., McCracken, L. M., Feliu‐Soler, A., Sanz, A., & Luciano, J. V. (2024) · Journal of Pain · doi:10.1016/j.jpain.2024.01.337 · Cited by 7 · see citing works
Mutyambizi-Mafunda, V., MYERS, B. J., Sorsdahl, K. R., Chanakira, E., Lund, C., & Cleary, S. (2021) · Global Health Action · doi:10.1080/16549716.2021.1972561 · Cited by 3 · see citing works
“[34] Informs resource allocation across health programs”
Dupont, J. K., Waldorff, F. B., & Graungaard, A. H. (2025) · BMC Primary Care · doi:10.1186/s12875-025-02970-3 · Cited by 1 · see citing works
Mental health prevention and promotion in general practice settings: A feasibility study
Budd, M., Bhutani, G., Gardner, K., Hann, M., Chauhan, U., Jaber, S., Shabir, I., Benedetto, V., Clegg, A., Lever, M., et al. (2025) · Mental Health & Prevention · doi:10.1016/j.mhp.2025.200402
Paredes-Gonzales, Y., Centeno-Terrazas, G., la Cruz-Torralva, K. D., Romani-Huacani, E., Lozada, Y. P. A.-M., & Villarreal‐Zegarra, D. (2025) · medRxiv · doi:10.1101/2025.05.05.25327011
Pan, D., & Rehbein, C. (2025) · Ecopsychology · doi:10.1177/19429347251406250
- Authors
- Sun, Y., Wong, S. Y. S., Zhang, D., Chen, C. H. J., & Yip, B. H. K.
- Affiliations
- Chinese University of Hong Kong (HK)
- National University of Singapore (SG)
- Corresponding author
- Yip, Benjamin H.K.
- Venue
- Journal of Psychiatric Research
- Publisher
- Elsevier BV
- Published
- 2021-01
- Volume
- 132
- Pages
- 111-115
- ISSN
- 0022-3956 (ISSN-L)
- OpenAlex
- W3093182004
- Cited by
- 11
- References
- 28
- Citations by year
- 2025: 5 · 2024: 1 · 2022: 3 · 2021: 2
- FWCI
- 1.06
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Psychiatric Research (publishedVersion)
- PubMed (publishedVersion)
- National University of Singapore (submittedVersion)
- Funders
- Health and Medical Research Fund (HMRF 11120501)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Keywords
- subthreshold depression, cost-utility analysis, cost-effectiveness, primary care, quality-adjusted life years, acceptability curves
- MeSH terms
- Adolescent, Adult, Cost-Benefit Analysis, Depression, Major Depressive Disorder, Humans, Primary Health Care, Quality of Life, Quality-Adjusted Life Years, Mindfulness
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
