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Utility Assessment in Patients with Mental Disorders

Validity and Discriminative Ability of the Time Trade-Off Method

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Abstract

Background: Preference-based health-state values, also referred to as utility scores, are considered an important measure of outcome in the evaluation of healthcare. A common approach to elicit utility scores is the use of the time trade-off (TTO) method; however, the data on TTO utility scores in patients with mental disorders are scarce.

Objective: To analyse the TTO method in patients with mental disorders in terms of discriminative ability, validity and the refusal to trade life time (zero trade).

Methods: In patients with affective (n = 172), schizophrenia spectrum (n = 166) and alcohol-related (n = 160) mental disorders, TTO utilities were administered through a standardized interview. Measures of quality of life (QOL) [EQ-5D, WHOQOL-BREF], subjective (SCL-90R) and objective (CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of TTO utilities. Validity was analysed by assessing the correlation of TTO utilities with all other scores. The association of a patient’s QOL, sociodemographic and disease-related variables with zero trade was analysed by logistic regression.

Results: Of patients with affective/schizophrenic/alcohol-related mental disorders, 153/143/145 (89/86/91%), respectively, completed the TTO elicitation; 29/43/28% of the respondents were zero traders. The mean TTO utility was 0.66/0.75/0.61 and the median was 0.85/0.95/0.75. TTO utility scores discriminated well among more impaired mental health states, but discrimination was limited among less impaired health states. In patients with affective and alcohol-related mental disorders, TTO utility scores were significantly correlated (mostly moderate: 0.3 < r < 0.5) with all other scores. However, in schizophrenic patients, TTO utility scores were only a little correlated with other subjective measures and not correlated with objective measures. QOL was significantly associated with zero trade; the influence of the other variables on zero trade was negligible.

Conclusions: TTO utility scores in patients with affective or alcohol-related mental disorders were reasonably valid, but discriminative ability was compromised by a ceiling effect due to zero trade. In schizophrenic patients, validity of TTO utility scores was not demonstrated.

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Notes

  1. Like other authors we use the terms ‘utility’ and ‘value’ interchangeably for numerical judgments of the desirability of health states,[1] although some authors restrict the term ‘utility’ specifically to utilities measured under uncertainty according to the axioms of expected utility theory.[2]

  2. Discriminative ability refers to whether the TTO method is able to differentiate between different states of mental health. Construct validity addresses whether TTO utility scores correspond to existing measures of theoretically related constructs.[12]

  3. Median TTO utility scores for subgroups defined by the first/second/third/fourth quartile of the WHOQOLBREF mental domain score were 0.50/0.75/0.93/1.0 for patients with affective disorders, 0.70/0.90/1.00/1.00 for patients with schizophrenia spectrum disorders and 0.60/0.75/0.80/1.00 for patients with alcohol-related mental disorders. The worst score of the WHOQOL-BREF mental domain, i.e. the lower limit of the first quartile subgroup, was 4.1/4.1/0.0 for patient groups with affective, schizophrenia spectrum and alcohol-related mental disorders, respectively. Median TTO utility scores for subgroups defined by the first/second/third/fourth quartile of the SCL-90R (GSI) score were 0.63/0.78/0.85/1.00 for patients with affective disorders, 0.53/0.97/0.85/1.00 for patients with schizophrenia spectrum disorders and 0.50/0.75/0.80/0.85 for patients with alcohol-related mental disorders. The worst score of the SCL-90R (GSI), i.e. the lower limit of the first quartile subgroup, was 3.17/2.64/3.52 for patient groups with affective, schizophrenia spectrum and alcohol-related mental disorders, respectively.

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Acknowledgements

This study was funded by the German Statutory Health Insurance (grant number 932000-050) and German Federal Ministry of Education and Research (grant number 01ZZ0106). The authors have no conflicts of interest that are directly relevant to the contents of this study.

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Authors and Affiliations

  1. Health Economics Research Unit, Department of Psychiatry, University of Leipzig, Johannisallee 20, D-04317, Leipzig, Germany

    Hans-Helmut König, Oliver H. Günther & Christiane Roick

  2. Center for Public Mental Health, Gösing am Wagram, Austria

    Matthias C. Angermeyer

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  1. Hans-Helmut König
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Correspondence to Hans-Helmut König.

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König, HH., Günther, O.H., Angermeyer, M.C. et al. Utility Assessment in Patients with Mental Disorders. Pharmacoeconomics 27, 405–419 (2009). https://doi.org/10.2165/00019053-200927050-00005

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