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QUESTION: How cost effective is cognitive therapy for preventing relapse in depression?
Design
Randomised controlled trial with allocation concealment. Outcome assessors were blind to treatment allocation. The reviewers audited blinding status and assessed inter-rater reliability.
Setting
United Kingdom; timeframe not specified.
Participants
158 people aged 21–65 years with partially remitted major depression, despite treatment. All participants had an episode of unipolar major depression satisfying DSM-III-R criteria within the past 18 months, but not in the past 2 months. At randomisation all participants had residual symptoms of at least 8 weeks duration, with a score of 8 or greater on the Hamilton Rating Scale for Depression and 9 or greater on the Beck Depression Inventory. Mean age 43 years; 49% women. People with a history of bipolar disorder or significant Axis I or Axis II comorbidity were excluded, as were those receiving formal psychotherapy and those who had received more than 5 sessions of cognitive therapy in the past.
Intervention
Participants received clinical management and antidepressants with or without cognitive therapy. The minimum dose of antidepressants was equivalent to 125 mg of amitryptiline. Clinical management comprised 30 minute appointments with a psychiatrist every 4 weeks for 20 weeks and every 8 weeks during 48-week follow up. Cognitive therapy comprised 16 sessions over 20 weeks, with two booster sessions.
Main outcome measures
The major outcomes were relapse rates and healthcare resource use measured prospectively over a 17 month period. The economic analysis comprised direct costs to the National Health Service. Indirect costs and non-health service expenditure were not considered.
Main results
In people receiving cognitive therapy, cumulative relapse rates were significantly lower than controls (29% v 47%). The overall mean cost of cognitive therapy was £1164 per person (95% CI £1084 to £1244, see table). The incremental cost effectiveness ratio ranged from £4328 to £5027 per additional relapse prevented.
Conclusions
In people with medication-resistant depression, adding cognitive therapy to standard treatment is more costly, but more effective, than antidepressants and clinical management alone. The cost of providing cognitive therapy is about £12.50 per additional relapse-free day.
Mean cost of treating people with partially remitted major depression
COMMENTARY
Although there is evidence that cognitive behaviour therapy (CBT) can reduce the risk of relapse, the actual costs of preventing such relapse have not been clearly described. This study assesses the cost effectiveness of adding CBT to clinical management and antidepressant medication for relapse prevention. The authors collated the costs of CBT therapists and other health services used. The findings suggest that adjunctive therapy decreases the risk of relapse and promotes more depression-free days. Cognitive therapy is expensive, however, costing £4000–5000 per relapse prevented.
This paper raises a number of intriguing questions about the effectiveness and costs of depression treatment. The first question is whether clinical management is needed if patients receive supervision by the CBT therapist during their CBT training sessions. Clinical management is an important ingredient in the outcome of depression.1 If clinical management could be achieved within CBT sessions, however, the relative cost of CBT may not be much greater than the costs of clinical management plus antidepressant medication. More importantly, alternatives to face to face CBT could be considered. There is increasing evidence that bibliotherapy, computer assisted CBT and internet assisted CBT effectively reduce symptoms of depression.2,3 Internet-based interventions are portable, accessible and personalised, and reminders can be automated. Although there are some caveats,4 developing an internet-based relapse prevention package may be a good investment.
Footnotes
Source of funding: UK Medical Research Council.
For correspondence: J Scott, Department of Psychological Medicine, Institute of Psychiatry, Kings College London, UK. j.scott{at}io.kcl.ac.uk