October 29, 2019
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CBT no more cost-effective than antidepressants for depression

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Eric L. Ross

Cognitive behavioral therapy and antidepressants have comparable efficacy and are both viable options for the initial treatment of major depressive disorder, research has shown. Now, new findings published in the Annals of Internal Medicine demonstrate that neither approach to treatment is superior in terms of cost-effectiveness.

Eric L. Ross, MD, a clinical fellow in psychiatry at Massachusetts General Hospital, told Healio Primary Care that these findings “clear the way for all of the other factors that go into shared decision-making — patient values and preferences, clinician experience, availability of providers, convenience, etc. — to really take center stage in guiding treatment decisions.”

Researchers quantified the cost-effectiveness of CBT and second-generation antidepressants in patients diagnosed with major depressive disorder using data from a meta-analysis of randomized control trials, and collected other clinical and economic data.

The study utilized a base-case model that simulated major depression across the different treatments, and a sensitivity and uncertainly analysis to assess findings to alternative modeling assumptions and determine the uncertainty of the results.

Depression 
Cognitive behavioral therapy and antidepressants have comparable efficacy and are both viable options for the initial treatment of major depressive disorder, research has shown. Now, new findings published in the Annals of Internal Medicine demonstrate that neither approach to treatment is superior in terms of cost-effectiveness.
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Researchers evaluated costs to patients from a health care perspective and from a societal perspective, which included costs from health care and those stemming from lost time and productivity.

Results of the base-case model showed that, in terms of quality-adjusted life-years, CBT had 3 more days at 1 year and 20 more days at 5 years compared with second-generation antidepressants.

CBT cost more at 1 year, with mean costs $900 higher in health care and $1,500 higher in the societal sector compared with second-generation antidepressants. However, CBT had lower costs at 5 years, with costs $1,800 lower in health care and $2,500 lower in the societal sector vs. second-generation antidepressants.

The sensitivity analysis showed that second-generation antidepressants were 64% to 77% more likely to be preferred based on monetary benefit at 1 year, but CBT was 73% to 77% more likely to be preferred at 5 years.

Researchers noted that the uncertainty of relative risk for depression relapse was the primary cause for the uncertainty in optimal treatment. They also noted that because neither treatment was more cost-effective and many patients express a preference for psychotherapy over medications, increasing access to CBT may be justified.

To help increase patient access to CBT, Ross suggested two methods; one “to rethink our approaches to reimbursement, referral, and provider training to increase the number of CBT providers and make referral as seamless as possible. The other is to rethink what CBT looks like — to try to find ways to use group therapy, telephone-based therapy, and internet-based therapy to enable each provider to effectively treat more patients.”

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In an editorial accompanying the study, Mark Sinyor, MSc, MD, of Sunnybrook Health Sciences Centre and the University of Toronto, wrote that “It is increasingly evident that differences in effectiveness between CBT and [second-generation antidepressants] are not substantial and that CBT has some advantages, including potentially lower long-term costs.”

He explained that although more research comparing outcomes between psychotherapy and medications is needed, second-generation antidepressants “are widely accessible in developed countries” and “CBT must become equally available.” – by Erin Michael

Disclosures: Ross reports grants from the NIMH during the conduct of the study. Please see study for all other authors’ relevant financial disclosures. Sinyor reports no relevant financial disclosures.