Original Title: Coste-efectividad de la terapia electroconvulsiva en el tratamiento de la depresión. Revisión sistemática y evaluación económica

Authors' objectives: To determine the effectiveness and safety of electroconvulsive therapy for the treatment of major depressive disorder, as well as knowledge and attitudes of patients and families to this therapeutic alternative. To determine the cost-effectiveness of electroconvulsive therapy for the treatment of major depressive disorder resistant to drug treatment compared to repetitive transcraneal magnetic stimulation

Authors' results and conclusions: RESULTS: A total of 1658 references were found in the electronic databases. After removing duplicates, 1582 references were obtained, of which 95 were selected. We finally included 18 studies: 11 SR with MA and 7 SR without MA. All the studies include persons with primary depressive disorders. Of 18 SR, 14 analyse the efficacy and effectiveness of ECT: 4 comparing ECT vs. several moderators, 4 associated with various conditions in which ECT was applied, 3 regarding different types of depression, 3 related to the moment of life and 2 about continuation/maintenance therapy. 6 RS which examine the safety of the technique and 1 which explores the knowledge and attitudes of patients concerning ECT were also identified. With regards to the evidence on cost-effectiveness, taking into account annual costs, the mean cost per patient treated with ECT was estimated to be 16846€, while the mean cost per patient treated with rTMS followed by ECT was 19749€. The mean QALY for those in the ECT arm was 0.210, while the mean QALY in the rTMS followed by ECT arm was 0.271. Therefore, the incremental cost-effectiveness ratio was 47523€/QALY which is higher than the willingness to pay used as a reference in this type of studies, 30000€/QALY. The sensitivity analysis indicates that for a willingness to pay of 30000€/QALY, the probability that rTMS followed by ECT is considered cost-effective is just above 25%. If we consider a willingness to pay of 60000€/QALY, this probability increases to 55%. CONCLUSIONS: ECT discloses to be significantly better than simulated ECT and pharmacotherapy for the short-term reduction of depressive symptoms, thought it seems to be necessary a continuation treatment in order to maintain the accomplished improvement. Regarding the different modalities of application of the technique, bifrontal ECT has a similar efficacy than bitemporal and unilateral; and higher doses of electrical charge, independently from the localization, become more effective. Regarding the type of depression, ECT seems to be more effective on psychotic than non-psychotic depression and on patients without resistance to pharmacological treatment than those which have not previously responded to it. As the safety of the technique, damage on several cognitive domains is observed immediately after the treatment. These effects are intense in the case of memory and executive functioning, and small to moderate for the rest. Nevertheless, recovery of damaged domains, even the improvement in several domains in comparison to basal line, is observed after a few days. Further controlled studies which confirm these data and analyze the safety of ECT when it is long-term applied are needed. ECT reveals to be more effective on reducing depressive symptoms than repetitive Transcranial Magnetic Stimulation (rTMS). Nevertheless, as the risk of adverse effects associated to the rTMS is lower, the choice from one technique and another must consider the preferences of patients, as well as the cost-effectiveness. With regards to the economic evaluation of ECT versus rTMS followed by ECT, we conclude that based on the available information and the estimated model results, we cannot recommend the introduction of rTMS as an alternative first line treatment to ECT for medicationresistant patients with major depression. Finally, this report has included a review concerning the knowledge and attitudes to ECT of patients. Although many patients have a positive perception and experience of ECT, the need for offering detailed and comprehensive information is highlighted.

Authors' recommendations: Application of ECT for the treatment of acute depression of patients with severe or treatment-resistant depression is recommended. As the uncertainty about its cognitive effects still remains, the choice of this intervention must consider a decision making process between the patient and his/her family. During the treatment process it is important to monitor the cognitive status of patients by using standardized instruments, as well as their perception about obtained benefits and adverse effects. Based on the information available and the results of the estimated model, and taking into account a threshold willingness to pay of € 30,000 / QALY, rTMS followed by ECT is considered more cost-effective than the application of ECT as first-line treatment, so it does not justify the introduction of rTMS initial alternative to ECT in patients with treatment-resistant major depression.

Authors' methods: A systematic review (SR) of the scientific evidence on the safety, effectiveness, and cost-effectiveness of ECT for the treatment of depression was conducted. To identify systematic reviews and metaanalysis on the subject, the following electronic databases were consulted: MEDLINE and PreMedline (1950-April 2013), EMBASE (1980- April 2013), PsycINFO (1887- April 2013), CINAHL (1982- April 2013), Cochrane Library (1982- April 2013), Centre for Reviews & Dissemination (1973- April 2013). This search strategy was complemented by manual bibliographic. Two reviewers performed the entire selection process of studies and in case of doubt or disagreement between them a third reviewer was consulted. The study selection was limited to those published in English and Spanish. The methodological quality of included studies was assessed using the Oxman scale. To identify economic evaluations and cost studies in Spain several searches in different structured information resources were conducted. In the economic evaluation, we compare the use of ECT with the use of rTMS as first line treatment, followed by ECT if rTMS fails, in patients with major depression resistant to pharmacotherapy. We applied a Markov model to synthesise the available information from the literature with respect to the effectiveness and costs of ECT and rTMS. The perspective taken was that of the National Health System (NHS) and the time horizon considered was one year. We measured effectiveness by the means of quality-adjusted life years. We performed a multivariate and stochastic sensitivity analysis by means of Monte Carlo simulations, allowing us to compute the acceptability curves and the expected value of perfect information.

Project Status: Completed

Year Published: 2013

URL for published report: https://sescs.es/terapia-electroconvulsiva-en-el-tratamiento-de-la-depresion/

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Canary Health Service

Contact Address: Dirección del Servicio. Servicio Canario de la Salud, Camino Candelaria 44, 1ª planta, 38109 El Rosario, Santa Cruz de Tenerife

Contact Name: sescs@sescs.es

Contact Email: sescs@sescs.es