CBT may offer equivalent value to antidepressants as initial therapy for major depression
In a decision analytic model, second-generation antidepressants had an approximately 70% likelihood of being more cost-effective at one year, while cognitive-behavioral therapy (CBT) had an approximately 75% likelihood of being superior at five years.
Increasing access to cognitive behavioral therapy (CBT) may offer similar value to second-generation antidepressants for major depressive disorder (MDD), a study found.
Researchers used relative effectiveness data from a meta-analysis to create a decision analytic model that quantified the cost-effectiveness of these two treatments for U.S. adults recently diagnosed with MDD. The results were published Oct. 29 by Annals of Internal Medicine.
Neither second-generation antidepressants nor CBT was consistently superior from a cost-effectiveness perspective. CBT had a higher initial cost, but over a five-year period, it was less costly while producing the same or greater improvement. At one year, there was an approximately 70% likelihood that antidepressants were the superior treatment from a cost-effectiveness perspective, and at five years, there was an approximately 75% likelihood that CBT was superior. CBT produced higher quality-adjusted life-years (QALYs) in model predictions (3 days more at one year and 20 days more at five years) with higher costs at one year (health care sector, $900; societal, $1,500) and lower costs at five years (health care sector, −$1,800; societal, −$2,500).
Probabilistic sensitivity analyses showed that second-generation antidepressants had a 64% to 77% likelihood of having an incremental cost-effectiveness ratio of $100,000 or less per QALY at one year, while CBT had a 73% to 77% likelihood at five years. Uncertainty in the relative risk for relapse of depression contributed the most to overall uncertainty about optimal treatment, the authors wrote. They concluded that in the absence of clear superiority of either treatment, shared decision making incorporating patients' preferences is critical. Given previous research indicating that patients seem to prefer CBT, efforts to improve access to psychotherapy may be warranted, they wrote. They noted that their results may be limited by the lack of long-term data comparing CBT and second-generation antidepressants.
An editorial pointed out 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. These must be balanced with the advantages of medications, such as potentially more rapid action as well as efficacy across the full severity spectrum of MDD, the editorialist wrote.
“Antidepressants for MDD are widely accessible in developed countries and that is important for our patients,” the editorial stated. “If we are serious about providing evidence-based care, CBT must become equally available.”