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Cost effectiveness of Combination Therapies in Severe Depression
By British Journal of Psychiatry,
Dec 1, 2006 - 3:24:17 PM
Psychological therapy and antidepressants given together (combination therapy) is likely to be a cost-effective treatment for severe depression, according to a new study.
But the cost-effectiveness of combination therapy for moderate depression is more uncertain.
The study, published in the December issue of the British Journal of Psychiatry, took the form of a decision analysis developed for the National Institute of Clinical Excellence (NICE, 2004) depression guideline to evaluate the likely costs and outcomes of the first-line use of antidepressant medication, or combination therapy, for moderate and severe depression in secondary care in the UK (National Collaborating Centre for Mental Health, 2005).
Systematic literature reviews were carried out to identify clinical, utility and cost data. A ‘decision analytic model’ was then developed to compare the effectiveness and costs of using antidepressant therapy alone with combination therapy for people with moderate and severe depression over a 3-month initial treatment period and 12-month follow-up.
The researchers chose cognitive behavioural therapy for their analysis, as it has a relatively large, high-quality evidence base compared with other psychological therapies provided by the NHS.
The antidepressant therapy consisted of 3 months of daily 40g fluoxetine, with an average of four specialist visits, assuming two visits by a consultant and two visits by a specialist registrar.
Combination therapy involved the use of this antidepressant treatment protocol and cognitive-behavioural therapy for 3 months. A full course included 16 sessions of about 50 minutes.
It was found that over the 15-month analysis period, combination therapy resulted in higher costs and an expected 0.16 increase per person in the probability of remission and no relapse, compared with antidepressants.
The cost per additional successfully treated patient was £4056. The cost per quality-adjusted life year gained was £5777 for severe depression, and £14,540 for moderate depression.
The results indicate that targeting combination therapy on severe forms of depression could be a more efficient way of using limited resources, say the researchers.
They comment that the cost results suggest that although the initial treatment cost of combination therapy is substantially higher, these costs are in part offset by savings from lower treatment costs in the subsequent year.
Based on this evidence, the NICE guideline for depression (2004) recommends combination therapy for severe depression and antidepressant therapy for moderate depression, with combination therapy as a second-line intervention.
Considering the importance of patient preference, recommendations are also made about the use of psychological interventions where patients declined antidepressant medication alone, or had previously not responded to it.
The consequent increase in the need for psychological treatments is likely to require additional resources in the NHS, mostly the cost and time implications of extra staff training and employment. These are currently under consideration by NICE and the NHS in England and Wales.
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