ECT cost effective in treatment-resistant depression

Electroconvulsive therapy might be a cost-effective treatment option for patients with treatment-resistant depression, results of a mathematical modeling analysis suggest.

The health-economic value of electroconvulsive therapy is most likely maximized when the intervention is tried after two failed lines of pharmacotherapy/psychotherapy, authors of the analysis said in JAMA Psychiatry.

“Increasing use of ECT by offering it earlier in the course of treatment-resistant depression could greatly improve outcomes for this difficult-to-treat patient population,” wrote Eric L. Ross, a medical student at the University of Michigan, Ann Arbor.

In clinical practice, patients with uncontrolled depression might not be offered electroconvulsive therapy for months or years, despite evidence from multiple studies that it is significantly more effective than pharmacotherapy in that setting, Mr. Ross and his coauthors in the university’s department of psychiatry wrote in their report.

One barrier to use of electroconvulsive therapy might be its cost, which they said can run in excess of $10,000 for initial therapy and maintenance treatments, compared with several hundred dollars for an antidepressant prescription.

However, data are limited showing the efficacy of electroconvulsive therapy in relation to that higher price tag. Accordingly, the investigators used a decision analytic model to simulate the clinical and economic effects of seven different electroconvulsive therapy treatment strategies, and calculated the incremental cost-effectiveness ratio of each.

Over a 4-year horizon, treatment with electroconvulsive therapy would reduce time with uncontrolled depression from 50%, down to 32.9%-37.1%, depending on the treatment strategy, the investigators found.

It was 74%-78% likely that electroconvulsive therapy would be cost effective, they added, based on commonly accepted cost-effectiveness thresholds, they said.

They found that third-line electroconvulsive therapy had an incremental cost-effectiveness ratio of $54,000 per quality-adjusted life-year. Based on that, investigators projected that the third-line strategy would be cost effective, considering a willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

Although offering electroconvulsive therapy after two lines of pharmacotherapy/psychotherapy maximized its health-economic value in this analysis, the treatment still would be cost effective in patients with three or more previous treatments, authors said.

Based on those findings, Mr. Ross and his coauthors said they would recommend that patients with major depressive disorder be offered ECT when two or more trials of pharmacotherapy or psychotherapy have failed. That aligns with other recent recommendations, including 2017 Florida best practice guidelines that classify ECT as a level 3 treatment option, they said.

Mr. Ross and his coauthors cited several limitations. One is that much of the input data used in the mathematical model is more than 10 years old. In addition, other novel interventions for treatment-resistant depression – such as repetitive transcranial magnetic stimulation – were not evaluated.

The study was supported by the Department of Veterans Affairs Health Services Research & Development Services. The study authors had no conflicts of interest to report.

SOURCE: Ross EL et al. JAMA Psychiatry. 2018 May 9. doi: 10.1001/jamapsychiatry.2018.0768..

Electroconvulsive therapy might be a cost-effective treatment option for patients with treatment-resistant depression, results of a mathematical modeling analysis suggest.

The health-economic value of electroconvulsive therapy is most likely maximized when the intervention is tried after two failed lines of pharmacotherapy/psychotherapy, authors of the analysis said in JAMA Psychiatry.

“Increasing use of ECT by offering it earlier in the course of treatment-resistant depression could greatly improve outcomes for this difficult-to-treat patient population,” wrote Eric L. Ross, a medical student at the University of Michigan, Ann Arbor.

In clinical practice, patients with uncontrolled depression might not be offered electroconvulsive therapy for months or years, despite evidence from multiple studies that it is significantly more effective than pharmacotherapy in that setting, Mr. Ross and his coauthors in the university’s department of psychiatry wrote in their report.

One barrier to use of electroconvulsive therapy might be its cost, which they said can run in excess of $10,000 for initial therapy and maintenance treatments, compared with several hundred dollars for an antidepressant prescription.

However, data are limited showing the efficacy of electroconvulsive therapy in relation to that higher price tag. Accordingly, the investigators used a decision analytic model to simulate the clinical and economic effects of seven different electroconvulsive therapy treatment strategies, and calculated the incremental cost-effectiveness ratio of each.

Over a 4-year horizon, treatment with electroconvulsive therapy would reduce time with uncontrolled depression from 50%, down to 32.9%-37.1%, depending on the treatment strategy, the investigators found.

It was 74%-78% likely that electroconvulsive therapy would be cost effective, they added, based on commonly accepted cost-effectiveness thresholds, they said.

They found that third-line electroconvulsive therapy had an incremental cost-effectiveness ratio of $54,000 per quality-adjusted life-year. Based on that, investigators projected that the third-line strategy would be cost effective, considering a willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

Although offering electroconvulsive therapy after two lines of pharmacotherapy/psychotherapy maximized its health-economic value in this analysis, the treatment still would be cost effective in patients with three or more previous treatments, authors said.

Based on those findings, Mr. Ross and his coauthors said they would recommend that patients with major depressive disorder be offered ECT when two or more trials of pharmacotherapy or psychotherapy have failed. That aligns with other recent recommendations, including 2017 Florida best practice guidelines that classify ECT as a level 3 treatment option, they said.

Mr. Ross and his coauthors cited several limitations. One is that much of the input data used in the mathematical model is more than 10 years old. In addition, other novel interventions for treatment-resistant depression – such as repetitive transcranial magnetic stimulation – were not evaluated.

The study was supported by the Department of Veterans Affairs Health Services Research & Development Services. The study authors had no conflicts of interest to report.

SOURCE: Ross EL et al. JAMA Psychiatry. 2018 May 9. doi: 10.1001/jamapsychiatry.2018.0768..

Electroconvulsive therapy might be a cost-effective treatment option for patients with treatment-resistant depression, results of a mathematical modeling analysis suggest.

The health-economic value of electroconvulsive therapy is most likely maximized when the intervention is tried after two failed lines of pharmacotherapy/psychotherapy, authors of the analysis said in JAMA Psychiatry.

“Increasing use of ECT by offering it earlier in the course of treatment-resistant depression could greatly improve outcomes for this difficult-to-treat patient population,” wrote Eric L. Ross, a medical student at the University of Michigan, Ann Arbor.

In clinical practice, patients with uncontrolled depression might not be offered electroconvulsive therapy for months or years, despite evidence from multiple studies that it is significantly more effective than pharmacotherapy in that setting, Mr. Ross and his coauthors in the university’s department of psychiatry wrote in their report.

One barrier to use of electroconvulsive therapy might be its cost, which they said can run in excess of $10,000 for initial therapy and maintenance treatments, compared with several hundred dollars for an antidepressant prescription.

However, data are limited showing the efficacy of electroconvulsive therapy in relation to that higher price tag. Accordingly, the investigators used a decision analytic model to simulate the clinical and economic effects of seven different electroconvulsive therapy treatment strategies, and calculated the incremental cost-effectiveness ratio of each.

Over a 4-year horizon, treatment with electroconvulsive therapy would reduce time with uncontrolled depression from 50%, down to 32.9%-37.1%, depending on the treatment strategy, the investigators found.

It was 74%-78% likely that electroconvulsive therapy would be cost effective, they added, based on commonly accepted cost-effectiveness thresholds, they said.

They found that third-line electroconvulsive therapy had an incremental cost-effectiveness ratio of $54,000 per quality-adjusted life-year. Based on that, investigators projected that the third-line strategy would be cost effective, considering a willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

Although offering electroconvulsive therapy after two lines of pharmacotherapy/psychotherapy maximized its health-economic value in this analysis, the treatment still would be cost effective in patients with three or more previous treatments, authors said.

Based on those findings, Mr. Ross and his coauthors said they would recommend that patients with major depressive disorder be offered ECT when two or more trials of pharmacotherapy or psychotherapy have failed. That aligns with other recent recommendations, including 2017 Florida best practice guidelines that classify ECT as a level 3 treatment option, they said.

Mr. Ross and his coauthors cited several limitations. One is that much of the input data used in the mathematical model is more than 10 years old. In addition, other novel interventions for treatment-resistant depression – such as repetitive transcranial magnetic stimulation – were not evaluated.

The study was supported by the Department of Veterans Affairs Health Services Research & Development Services. The study authors had no conflicts of interest to report.

SOURCE: Ross EL et al. JAMA Psychiatry. 2018 May 9. doi: 10.1001/jamapsychiatry.2018.0768..