1. In this modeling study comparing the cost-effectiveness of cognitive behavioral therapy (CBT) with second-generation antidepressants (SGA) for initial treatment of depression, neither strategy provided consistently superior economic outcomes. However, over the long term, it is possible that increased use of CBT may generate significant savings.
2. Given patient preferences for psychotherapy over pharmacotherapy, increasing access to CBT may be worthwhile.
Evidence Rating Level: 3 (Average)
Study Rundown: Major depressive disorder (MDD) is a significant cause of morbidity worldwide with an estimated prevalence of 7.3% in the United States and an annual economic cost of the condition exceeding $210 billion. American College of Physicians guidelines recommend treatment through either cognitive behavioral therapy (CBT) or a second-generation antidepressant (SGA), which have been shown to be similar in efficacy and safety outcomes. Although the majority of patients prefer psychotherapy over pharmacotherapy, fewer than one quarter of MDD patients receive psychotherapeutic intervention likely due to prohibitively high initial costs. Prior studies have illustrated major differences in cost-effectiveness of the two treatments dependent on patient demographic, and this study aimed to extrapolate conclusions to the greater U.S. population as well as provide evidence to better inform future policymaking. According to decision analytic model projections, CBT produced higher quality adjusted life years (QALYs) with higher costs at one year but improved cost-effectiveness over time. The primary driver of decision uncertainty was found to be relative relapse rate of CBT versus SGA, highlighting the importance of treatment durability. Overall, neither treatment was found to be conclusively superior with regard to cost-effectiveness, suggesting that patient preference ought to be a critical factor in shared decision-making. Strengths of this study included multiple sources of data input, acknowledgement of indirect costs, adequate model validation, and incorporation of sensitivity analyses. Conversely, this study was severely limited by the lack of evidence regarding long-term outcomes. Patients were not stratified by clinically important factors such as depression severity, and conclusions drawn regarding safety and efficacy required substantial extrapolation of short-term data, which contributed greatly to model uncertainty.
Relevant Reading: Treatment of Adult Depression in the United States
In-Depth [retrospective cohort]: This decision analytic modeling study was conducted using data from meta-analysis of randomized clinical trials as well as additional clinical and economic data from existing literature. The primary outcomes assessed were costs presented in 2014 U.S. dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. The metric of net monetary benefit (NMB) was established using projected QALYs gained, projected cost, and the willingness-to-pay threshold (defined as $100,000/QALY gained). According to base-case results at 1 year, CBT was found to produce greater survival by 0.008 QALYs (3 days) at unacceptable cost ($186,000/QALY gained) with an inconclusive incremental NMB (CI, -$3400 to $1600). At 5 years, CBT increased QALYs by 0.055 (20 days) and reduced costs by approximately $2000 compared to SGA. However, cost-effectiveness remained uncertain according to NMB (CI, -$10,400 to $25,300). Probabilistic sensitivity analyses were also conducted, and the average results of 10,000 runs were used to calculate the following confidence intervals. SGA had a 64%-77% likelihood of having an incremental cost-effectiveness ratio of $100,000 or less per QALY at 1 year, whereas CBT had a 73%-77% likelihood at 5 years. Given these findings and considering inclinations for psychotherapy, improving access to CBT is warranted; shifting from the status quo to patient-preferred levels of CBT use could save more than $1.5 billion over 5 years.
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