Economics

In treatment-resistant depression, adding cognitive–behavioral therapy to usual care was cost-effective at 1 y

Hollinghurst S, Carroll FE, Abel A, et al. Cost-effectiveness of cognitive-behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: economic evaluation of the CoBalT Trial. Br J Psychiatry. 2014;204:69-76.

Clinical impact ratings: F ★★★★★★✩ M ★★★★★★✩ Question

Conclusion

In primary care patients with treatment-resistant depression, is adding individual cognitive–behavioral therapy (CBT) to usual care cost-effective?

In primary care patients with treatment-resistant depression in the UK, adding cognitive–behavioral therapy to usual care was cost-effective at 1 year.

Methods

*www.oanda.com/currency/historical-rates (accessed 24 Mar 2014).

Design: Cost-utility analysis from a UK National Health Service (NHS) and Personal Social Services (PSS) perspective based on 1-year follow-up of a randomized controlled trial (CoBalT trial). Setting: Primary care practices in Bristol, Exeter, and Glasgow, UK. Patients: 469 patients 18 to 75 years of age (mean age 50 y, 72% women) who were adherent to antidepressant medication for ≥ 6 weeks but continued to have depressive symptoms, had depression diagnosed using the Revised Clinical Interview Schedule, and had a Beck Depression Inventory (BDI)-II score ≥ 14. Intervention: Individual CBT, 12 to 18 one-hour sessions done in primary care practices or similar settings, plus usual care (n = 234), or usual care alone (n = 235). Usual care could include antidepressant drugs. Outcomes: Treatment response (≥ 50% reduction in BDI-II score); quality-adjusted life-years (QALYs), based on EQ-5D-3L scores and quality-of-life valuations from the UK general population; costs in 2010 UK pounds sterling {UK £1 = US $1.56}*; and incremental cost-effectiveness ratio (ICER). Costs included NHS and PSS costs obtained from primary care records, CBT therapist records, and patient questionnaires. Follow-up was 83% to 84% for clinical outcomes and 78% for health and social care costs at 1 year.

Main results Adding CBT to usual care reduced depression symptoms and increased QALYs (Table). CBT plus usual care cost more than usual care alone (Table), with an ICER of £14 911 (US $23 261) per QALY gained over 12 months. In sensitivity analyses using the Short Form-6 dimensions algorithm to estimate QALYs, the ICER was £29 626 (US $46 217). Cost-effectiveness of CBT plus UC vs UC alone in primary care patients with treatment-resistant depression† Outcomes

CBT + UC

UC

Response‡

55%

31%

At 1 y RBI (95% CI) 82% (54 to 108)

NNT (CI) 4 (3 to 6)

Difference (CI) Mean QALYs§ Mean total NHS and PSS costs§||

0.61

0.55

0.057 (0.015 to 0.099)

£1614

£763

£850 (£683 to £1017)

†CBT = cognitive–behavioral therapy; NHS = UK National Health Service; PSS = UK Personal Social Services; QALY = quality-adjusted life-year; UC = usual care; other abbreviations defined in Glossary. RBI, NNT, and CI calculated using odds ratio and control event rate in article. ‡≥ 50% reduction from baseline in Beck Depression Inventory-II score. §Missing QALY and cost data estimated using multiple imputation. ||US $2518 vs $1190, difference $1326 (95% CI 1065 to 1587); converted from UK pounds sterling using the mean 2010 exchange rate of 1.56.

17 June 2014 | ACP Journal Club | Volume 160 • Number 12

Source of funding: National Institute for Health Research Health Technology Assessment programme. For correspondence: Dr. S. Hollinghurst, University of Bristol, Bristol, England, UK. E-mail [email protected]

Commentary Results of the trial by Hollinghurst and colleagues add to evidence about the incremental costs and benefits of interventions to improve treatment of depression in primary care. Several dimensions can be considered. First, care improvement programs have included pharmacotherapy alone, a choice or mixture of treatments, and such structured psychotherapy as that used in CoBalT. Clinical effectiveness is well-established across this spectrum (1). Second, intensity of programs has ranged from minimal (a few online messages or brief telephone contacts) to substantial (12 to 18 one-h psychotherapy sessions as provided in CoBalT). Across trials, the incremental clinical benefit and added cost vary in proportion to intervention intensity (2). Consequently, incremental cost per added QALY or added day free of depression is generally similar for a wide range of intervention intensities. The message to policymakers is that small investments can produce positive returns, but larger investments are likely to produce much larger returns—that is, you get what you pay for. Third, the relation between inputs and outputs varies with the quality of usual care. In general, the greatest benefits and most favorable balance of benefits and costs have occurred in settings or patient populations where access to, or quality of, depression treatment is poor (3). Whether poorly served patients are in lower-income countries or disadvantaged populations in the USA, quality improvement seems to have the most robust benefits when initial quality is low. Fourth, the potential for health service cost savings depends on the level of pretreatment costs. Depression care improvement programs in patients with chronic medical illness and high pretreatment use have sometimes reduced overall use or costs of health services (the much sought-after “cost-offset” effect) (4). However, trials in younger or mixed-age populations have typically found increases in health service costs (2). For younger, healthier primary care patients, the economic benefits of better depression treatments accrue outside of the health care system— to patients, their families, and their employers. Gregory Simon, MD, MPH Group Health Research Institute Seattle, Washington, USA References 1. Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Br J Psychiatry. 2006;189:484-93. 2. Simon GE, Ludman EJ, Rutter CM. Arch Gen Psychiatry. 2009;66:1081-9. 3. Araya R, Flynn T, Rojas G, Fritsch R, Simon G. Am J Psychiatry. 2006; 163:1379-87. 4. Simon GE. JAMA Intern Med. 2013;173:1004-5. © 2014 American College of Physicians

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ACP Journal Club. In treatment-resistant depression, adding cognitive-behavioral therapy to usual care was cost-effective at 1 y.

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