23 Nov 2021

Dijk HH et al. J Child Adolesc Psychopharmacol 2021; 31: 578-596

This systematic review aimed to provide an overview of economic evaluations of ADHD treatments in order to identify which treatments for ADHD are cost-effective, evaluate their outcomes and highlight gaps in the literature.

Electronic databases were searched for full economic evaluations of ADHD treatments for children, adolescents or adults published in English or Dutch, up to January 2021. Studies on the cost-effectiveness of pharmacological and non-pharmacological interventions for individuals with ADHD in all age groups were included, and the quality of all included studies was assessed with the Consensus Health Economic list (CHEC).* Primary outcomes were the reported cost-effectiveness and cost-utility estimates of treatment. To assess whether interventions were cost-effective, they were compared to a willingness-to-pay threshold of €29,000, with any interventions above this value considered to be not cost-effective.

In total, 29 studies were included in this review. Most studies comparing stimulant to non-stimulant treatment in children and adolescents found that stimulant treatment was cost-effective; the exception was atomoxetine, where evidence about cost-effectiveness was mixed. In addition, stimulant treatment was found to have lower cost and higher efficiency compared to behavioural treatment. The authors also noted behavioural parent training for ADHD to be a cost-effective treatment option compared to treatment as usual, and that parent training appeared more cost-effective when combined with a school-based intervention, such as teacher training. Almost all studies that compared medication or psychosocial treatment to no treatment, placebo or treatment as usual indicated that medication and psychosocial treatment were cost-effective compared with a control condition. However, the authors acknowledged that a small number of studies focus on treatments in adults and psychosocial treatments, and there are limited studies on long-term outcomes and studies independent of industry funding.

An average quality score of 69% (95% confidence interval 52–87) was found after assessment with the CHEC; the authors subsequently suggested that the quality of current cost-effectiveness research could be improved. The included studies scored well on items related to the research question and objective, economic design, time horizon, identification of alternative outcomes and reporting of an incremental cost-effectiveness ratio. In contrast, studies scored considerably lower on items related to description of the model and assumptions, discussion on the generalisability of the results, conflict of interest, and discussion on ethical and distributional issues.

Some limitations of this review were noted. Firstly, the included studies all assessed the cost-effectiveness of the same comparators; the authors acknowledged the importance of considering the country of study when interpreting the results due to differences in healthcare systems, costs of medication and societal context of each country, as well as differences in the design of the studies, which may have affected the outcomes. In addition, this review did not assess possible publication bias. Finally, the generalisability of the results outside high-income countries may be limited, as few studies on middle- and low-income countries were included in this systematic review.

It was concluded that treating ADHD (medication or psychosocial) is generally cost-effective compared with no treatment, care as usual or placebo. The authors acknowledged that, despite increasing interest in cost-effectiveness, there remains a need for more cost-effectiveness research of higher quality to optimise the treatment of individuals with ADHD. It was proposed that future studies should focus on treatments in adults and psychosocial treatments, consider long-term outcomes and be independent of industry funding.

Read more about the cost-effectiveness of ADHD treatment here


*The CHEC is a 19-item questionnaire used for assessment of the quality of economic evaluations in systematic reviews (Evers et al, 2005)
Willingness to pay generally described how much an individual, or society, is willing to pay for one additional quality-adjusted life year

Disclaimer: The views expressed here are the views of the author(s) and not those of Takeda.

Dijk HH, Wessels LM, Constanti M, et al. Cost-effectiveness and cost utility of treatment of attention-deficit/hyperactivity disorder: a systematic review. J Child Adolesc Psychopharmacol 2021; 51: 578-596.

Evers E, Goossens M, de Vet H, et al. Criteria list for assessment of methodological quality of economic evaluations: consensus on Health Economic Criteria. Int J Technol Assess Health Care 2005; 21: 240-245.

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