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Relative Cost-Effectiveness of Treatments for Adolescent Depression: 36-Week Results From the TADS Randomized Trial

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Abstract

Objective

The cost-effectiveness of three active interventions for major depression in adolescents was compared after 36 weeks of treatment in the Treatment of Adolescents with Depression Study.

Method

Outpatients aged 12 to 18 years with a primary diagnosis of major depression participated in a randomized controlled trial conducted at 13 U.S. academic and community clinics from 2000 to 2004. Three hundred twenty-seven participants randomized to 1 of 3 active treatment arms, fluoxetine alone (n = 109), cognitive-behavioral therapy (n = 111) alone, or their combination (n = 107), were evaluated for a 3-month acute treatment and a 6-month continuation/maintenance treatment period. Costs of services received for the 36 weeks were estimated and examined in relation to the number of depression-free days and quality-adjusted life-years. Cost-effectiveness acceptability curves were also generated. Sensitivity analyses were conducted to assess treatment differences on the quality-adjusted life-years and cost-effectiveness measures.

Results

Cognitive-behavioral therapy was the most costly treatment component (mean $1,787 [in monotherapy] and $1,833 [in combination therapy], median $1,923 [for both]). Reflecting higher direct and indirect costs associated with psychiatric hospital use, the costs of services received outside Treatment of Adolescents with Depression Study in fluoxetine-treated patients (mean $5,382, median $2,341) were significantly higher than those in participants treated with cognitive-behavioral therapy (mean $3,102, median $1,373) or combination (mean $2,705, median $927). Accordingly, cost-effectiveness acceptability curves indicate that combination treatment is highly likely (>90%) to be more cost-effective than fluoxetine alone at 36 weeks. Cognitive-behavioral therapy is not likely to be more cost-effective than fluoxetine.

Conclusions

These findings support the use of combination treatment in adolescents with depression over monotherapy. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(7):711–720

Section snippets

Method

The TADS was a multisite, randomized, 36-week clinical trial comparing the effectiveness of FLX, CBT, and combination treatment for the treatment of adolescents with major depression. For the first 12 weeks (stage 1), clinical management with pill placebo was also included, allowing for a double-blind comparison with FLX. Active treatment responders or partial responders, defined as at least minimally improved on a clinician-assigned Clinical Global Impressions score, progressed to a 6-week

Results

The average age of study participants at baseline was just younger than 15 years, and 55% were female subjects (Table 1). The average CDRS-R score decreased from a baseline average of 60 to a 36-week average of 29. The average number of DFDs over the 252-day interval was 135, ranging from 0 to 238, yielding an average DFD-QALY of 0.56 out of a potential maximum of 0.69 for 36 weeks. The exploratory QALY developed from the PQ-LES-Q had a similar average of 0.58. The mean HoNOSCA score dropped

Discussion

In the TADS, the accelerated response from medication treatment7, 8 combined with the lower costs of external services for CBT treatments ($2,700–$3,100 for combination treatment or CBT, respectively, as compared with $5,400 for FLX alone) yielded evidence favoring combination treatment with a high level of certainty (>90%) over FLX. No evidence of differential cost-effectiveness between CBT and FLX was detected. Increased rates of suicidal events in depressed patients treated with newer

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  • Cited by (0)

    This work was supported by contract N01 MH80008 from the National Institute of Mental Health to Duke University Medical Center (John S. March, Principal Investigator). Additional support was received by M.E.D. under K01-MH065639.

    Dr. Domino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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