Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor-resistant depression: treatment of SSRI-resistant depression in adolescents trial findings

Abstract

Context: Many youth with depression do not respond to initial treatment with selective serotonin reuptake inhibitors (SSRIs), and this is associated with higher costs. More effective treatment for these youth may be cost-effective.

Objective: To evaluate the incremental cost-effectiveness over 24 weeks of combined cognitive behavior therapy plus switch to a different antidepressant medication vs medication switch only in adolescents who continued to have depression despite adequate initial treatment with an SSRI.

Design: Randomized controlled trial.

Setting: Six US academic and community clinics.

Patients: Three hundred thirty-four patients aged 12 to 18 years with SSRI-resistant depression.

Intervention: Participants were randomly assigned to (1) switch to a different medication only or (2) switch to a different medication plus cognitive behavior therapy.

Main outcome measures: Clinical outcomes were depression-free days (DFDs), depression-improvement days (DIDs), and quality-adjusted life-years based on DFDs (DFD-QALYs). Costs of intervention, nonprotocol services, and families were included.

Results: Combined treatment achieved 8.3 additional DFDs (P = .03), 0.020 more DFD-QALYs (P = .03), and 11.0 more DIDs (P = .04). Combined therapy cost $1633 more (P = .01). Cost per DFD was $188 (incremental cost-effectiveness ratio [ICER] = $188; 95% confidence interval [CI], -$22 to $1613), $142 per DID (ICER = $142; 95% CI, -$14 to $2529), and $78,948 per DFD-QALY (ICER = $78,948; 95% CI, -$9261 to $677,448). Cost-effectiveness acceptability curve analyses suggest a 61% probability that combined treatment is more cost-effective at a willingness to pay $100,000 per QALY. Combined treatment had a higher net benefit for subgroups of youth without a history of abuse, with lower levels of hopelessness, and with comorbid conditions.

Conclusions: For youth with SSRI-resistant depression, combined treatment decreases the number of days with depression and is more costly. Depending on a decision maker's willingness to pay, combined therapy may be cost-effective, particularly for some subgroups.

Trial registration: clinicaltrials.gov Identifier: NCT00018902.

Figures

Figure 1

Study participants from prescreening through analysis. RX indicates medication switch only; RX + CBT, combined medication switch and cognitive behavior therapy; and TORDIA, Treatment of SSRI-Resistant Depression in Adolescents.

Figure 2

Proportion of days that are depression free across 24 weeks in the medication switch only (RX) and combined medication switch and cognitive behavior therapy (RX + CBT) groups.

Figure 3

Cost-effectiveness planes for the base case analysis. Incremental total costs at 24 weeks are shown by incremental Children’s Depression Rating Scale–Revised (CDRS-R) depression-free days (DFDs) (A) and incremental depression-improvement days (DIDs) (B). The model used 1000 replications adjusted for site, age, baseline CDRS-R score, baseline cost, race, and sex differences.

Figure 4

Cost-effectiveness acceptability curve for the base case analysis showing quality-adjusted life-years based on depression-free days at week 24. RX + CBT indicates combined medication switch and cognitive behavior therapy.

Figure 5

Cost-effectiveness acceptability curves showing quality-adjusted life-years based on depression-free days at week 24 for the full sample (A) and for subgroups according to history of abuse (B), comorbidities (C), and hopelessness (D). RX + CBT indicates combined medication switch and cognitive behavior therapy.