Eric L. Ross, MD; Sandeep Vijan, MD; Erin M. Miller, MS; Marcia Valenstein, MD; Kara Zivin, PhD
Grant Support: This study was supported by the U.S. Department of Veterans Affairs (Health Services Research and Development grants CD2 07-206, IIR 10-176, and IIR 14-324) and the National Institute of Mental Health (Research Training and Career Development grant R25MH094612).
Disclosures: Dr. Ross reports grants from the National Institute of Mental Health during the conduct of the study. Dr. Vijan reports grants from Department of Veterans Affairs (CD2 07-206-1) during the conduct of the study. Dr. Zivin reports a grant from Department of Veterans Affairs (CD2 07-206-1) during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-1480.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol and data set: Not available. Statistical code: Available from Dr. Ross (e-mail, firstname.lastname@example.org).
Corresponding Author: Eric L. Ross, MD, Massachusetts General Hospital, Wang 812, 15 Parkman Street, Boston, MA 02114; e-mail, email@example.com.
Current Author Addresses: Dr. Ross: Massachusetts General Hospital, Wang 812, 15 Parkman Street, Boston, MA 02144.
Dr. Vijan: University of Michigan Internal Medicine, 375 Briarwood Circle, Building 3, Ann Arbor, MI 48108.
Ms. Miller and Dr. Zivin: University of Michigan North Campus Research Center, Building 16, 2800 Plymouth Road, Room 228W, Ann Arbor, MI 48109.
Dr. Valenstein: University of Michigan North Campus Research Center, Building 16, 2800 Plymouth Road, Room 242E, Ann Arbor, MI 48109.
Author Contributions: Conception and design: E.L. Ross, S. Vijan, M. Valenstein, K. Zivin.
Analysis and interpretation of the data: E.L. Ross, S. Vijan, M. Valenstein, K. Zivin.
Drafting of the article: E.L. Ross, K. Zivin.
Critical revision of the article for important intellectual content: E.L. Ross, S. Vijan, M. Valenstein, K. Zivin.
Final approval of the article: E.L. Ross, S. Vijan, E.M. Miller, M. Valenstein, K. Zivin.
Provision of study materials or patients: E.M. Miller.
Statistical expertise: E.L. Ross, S. Vijan, K. Zivin.
Obtaining of funding: K. Zivin.
Administrative, technical, or logistic support: E.L. Ross, E.M. Miller, K. Zivin.
Collection and assembly of data: E.L. Ross, K. Zivin.
Most guidelines for major depressive disorder recommend initial treatment with either a second-generation antidepressant (SGA) or cognitive behavioral therapy (CBT). Although most trials suggest that these treatments have similar efficacy, their health economic implications are uncertain.
To quantify the cost-effectiveness of CBT versus SGA for initial treatment of depression.
Decision analytic model.
Relative effectiveness data from a meta-analysis of randomized controlled trials; additional clinical and economic data from other publications.
Adults with newly diagnosed major depressive disorder in the United States.
1 to 5 years.
Health care sector and societal.
Initial treatment with either an SGA or group and individual CBT.
Costs in 2014 U.S. dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.
In model projections, CBT produced higher QALYs (3 days more at 1 year and 20 days more at 5 years) with higher costs at 1 year (health care sector, $900; societal, $1500) but lower costs at 5 years (health care sector, −$1800; societal, −$2500).
In probabilistic sensitivity analyses, SGA had a 64% to 77% likelihood of having an incremental cost-effectiveness ratio of $100 000 or less per QALY at 1 year; CBT had a 73% to 77% likelihood at 5 years. Uncertainty in the relative risk for relapse of depression contributed the most to overall uncertainty in the optimal treatment.
Long-term trials comparing CBT and SGA are lacking.
Neither SGAs nor CBT provides consistently superior cost-effectiveness relative to the other. Given many patients' preference for psychotherapy over pharmacotherapy, increasing patient access to CBT may be warranted.
Department of Veterans Affairs, National Institute of Mental Health
Ross EL, Vijan S, Miller EM, et al. The Cost-Effectiveness of Cognitive Behavioral Therapy Versus Second-Generation Antidepressants for Initial Treatment of Major Depressive Disorder in the United States: A Decision Analytic Model. Ann Intern Med. 2019;:. [Epub ahead of print 29 October 2019]. doi: https://doi.org/10.7326/M18-1480
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Published: Ann Intern Med. 2019.
Healthcare Delivery and Policy, High Value Care.
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