Putting people with advanced Parkinson’s disease on device-aided therapies can, during the best of times, involve some tricky cost-benefit analysis. The COVID-19 pandemic has made that equation even more complicated.

According to a new study published in the journal Neurological Sciences, patients using these devices are experiencing significantly increased levels of anxiety and depression, and so are their caregivers. That’s thanks to decreased access to care and worry about the virus.

“These findings are important for neurologists and healthcare services to foster strategies for the management of psychological distress in both patients and caregivers,” the authors write.

These findings will also, undoubtedly, play a role in whether to move patients onto these devices in the first place, and which one to choose.

Examples of device-aided therapies (DAT) include deep brain stimulation (DBS), intrajejunal levodopa-carbidopa infusion (IJLI), and continuous subcutaneous apomorphine infusion (CSAI).

DATs can significantly improve quality of life in patients with advanced Parkinson disease, for whom oral medications have lost their efficacy. However, according to a 2021 review of cost-effectiveness for these devices across countries, they are often underutilized because they’re so expensive.

And cost-effectiveness itself may be quite nuanced, depending on the device, the time span it will be in use, and the condition/preference of the patient and caregivers.

In their Neurological Sciences review, the authors conclude that DBS, IJLI, and CSAI all improved “quality of life compared to best medical treatment with oral therapies.” This was particularly true when looking at treatment over “long temporal horizons.”

Because there is no standardized way of determining cost-effectiveness, the authors used cost per adjusted year of life gained compared with the gross domestic product per capita of the country where the patient is treated.

DBS stood out in their review as the most cost-effective, with infusion therapies showing less uniformity in that regard. Considering the high upfront costs for DBS, its value further increases when used for 10 years or longer.

Other cost/benefit factors include disease duration, age, availability of care and device maintenance, caregiver burden, and cognitive and psychiatric issues. Those last two are particularly relevant during the ongoing pandemic due to new findings that many advanced Parkinson’s disease patients and their caregivers are suffering from increased anxiety and depression.

In the case of DBS, increased levels of depression may also be of particular concern since this psychiatric illness can be a disqualifier for getting the device in the first place. For a decision that has only gotten more complex, choosing the right treatment for the right patient, the review authors write, “requires a careful process, in which the patient’s and [caregivers’] preferences and the clinician’s expertise contribute equally to the decision.”