An hour in talk therapy with a trained counsellor costs much more, and takes more time, than swallowing an inexpensive anti-depressant pill, but the costs and benefits of the two approaches end up being equal after five years, a new study has revealed.
The analysis, conducted using real-world data on treatment costs, positive and negative health effects, and impacts of treatment and depression symptoms on productivity, could help guide future care and insurance coverage. The findings of the research were published in the Journal Annals of Internal Medicine 2019.
The study suggests that more people newly diagnosed with depression should have a chance to try individual and group sessions of cognitive behavioural therapy, or CBT, as their first treatment, if they would prefer therapy overtaking an antidepressant medication.
National physician groups such as the American College of Physicians endorse giving people newly diagnosed with depression the option to choose either approach. But this would mean expanding the capacity of the health-care system to provide greater access to psychotherapy than is currently available.
However, making CBT more available could save money for the companies and government agencies that pay for depression care — including by giving patients more depression-free time leading to improved performance at work.
“One might assume that antidepressants are more cost-effective than psychotherapy because they don’t require travel time, time away from work, and as many contacts with providers as therapy do,” says first author Eric L. Ross, M.D., a psychiatrist at Harvard Medical School, Massachusetts General Hospital, and McLean Hospital. “But when incorporating the long-term effectiveness of each treatment, we found that neither treatment is consistently superior to the other.”
“Since CBT and antidepressants are roughly equivalent from a health-economic perspective, other factors should determine what treatment and individual patient receives — and the most important factor is the patient’s values and preferences,” says Kara Zivin, Ph.D., senior author of the new study and a professor of psychiatry at the University of Michigan Medical School. Zivin is also a member of the VA Center for Clinical Management Research.
Ross, Zivin and their colleagues built a detailed health economic model of depression treatment and added data from national clinical trials and sources of cost data.
Their results show that after one year, antidepressants do indeed cost much less, even when taking into account the physician visits needed to monitor treatment.
But after factoring in evidence about depression patients’ frequent need to try multiple medications before finding one that works for them, and their chance of going off their medications due to side effects and suffering a relapse, the balance of cost-effectiveness became more equivocal.
This new analysis adds to the evidence base about the cost-effectiveness of two commonly used depression treatments, and could thus guide treatment decisions, Zivin noted, but more research is needed to get updated results about the long-term effects of the two options pitted head-to-head in a real-world setting.
She also noted that the effects of health policy changes in recent years — requiring parity for mental health care for people covered by large private insurers, for instance, or allowing people in rural areas to receive CBT via video chat with a provider — should be measured too.
In the end, though, the shortage of trained mental health providers may do more to govern what kind of treatment patients receive.
“The demand for mental health treatment exceeds the current and projected number of clinicians specializing in psychiatry and related mental health professions,” Zivin says.
Research indicates that the majority of people with depression would prefer to receive therapy instead of medications, but only one-quarter of them actually receive therapy. The Veterans Health Administration, though, has succeeded in increasing the percentage of veterans receiving CBT in recent years.
“Often we think about these calculations in the short term, because insurance coverage is year to year,” Zivin observed. “But if we see effects like these in under five years, perhaps our society will be more willing to bear the upfront costs in order to avoid the indirect costs of missed work and under-productivity later on.”
Oct 31, 2019 14:46 IST