Original Title: Fármacos antidepresivos y tratamientos psicológicos para los trastornos depresivos: una revisión y evaluación económica

Authors' objectives: Depression is associated with considerable morbidity, mortality and costs. Several treatments can improve the quality of life, increase the time free of disease and reduce the burden of the illness for the society. The objectives of this study were 1) to review the best quality evidence for the clinical effectiveness of psychotherapy vs. antidepressants vs. combined therapy in depressed patients, and 2) to review the literature on economic evaluations and to determine whether cognitive therapy (CT) alone is cost-effective compared to antidepressants alone (paroxetine) in moderate depressed patients in Spain from the National Health System perspective and the societal perspective.

Authors' results and conclusions: RESULTS: Review on effectiveness: Two literature searches were performed: one looking for SR and one looking for RCT. The first one retrieved 6,227 references; from those 13 studies were included (1 was identified in the hand search). The second one retrieved 1,429 references, and 17 of these were included (4 of them were provided by the hand search), making reference to 13 studies. Review on cost-effectiveness: 204 references were identified, 10 papers were finally included in the review: 6 SR and 4 economic evaluations. We excluded an important number of studies because they compared different drugs within each other or with placebo. Previous economic evaluations informed different ICER of combined therapy in comparison to drug therapy, from 5,777 £/QALY (2003) to 45,741 $/QALY (1991). Economic evaluation: The direct health care cost is higher in the psychotherapy alternative than in the antidepressant one. The indirect cost due to lost of temporal productivity increases the cost of both alternatives. The ICERs from the National Health System perspective were estimated in 10.51 €/DFD and 12,792 €/QALY. The ICERs from the societal perspective were estimated in 5.56 €/DFD and 6,767 €/QALY. The antidepressant alternative was dominated by psychotherapy, that is, it was more expensive and less effective, when the indirect costs were estimated for a unit cost based on the average wage instead of the minimum wage. The results of the probabilistic sensitivity analysis altered the results of the base case: psychotherapy alone is not always a cost-effective alternative because the uncertainty about its costeffectiveness is not low even for high willingness to pay. CONCLUSIONS: In general, there are no differences in effectiveness between drug treatment and psychotherapy at the end of treatment, whether an acute or a continuation treatment. This conclusion should be restricted to studies that include patients with major depressive disorder, because in two studies which included patients with dysthymia, the administration of sertraline (alone or in combination with psychotherapy) gets a significantly higher efficiency that interpersonal psychotherapy. When we talk about assessments during follow-up, i.e., a time after therapy, revisions included report fewer relapses in treated groups with psychotherapy, although the number of RCT reporting these data is not enough to state definitive conclusions. It is believed that it may encourage individuals in activation of certain psychological factors of protection against relapse, but it is possible that these benefits are not continued after a year and a half or two years. In any case, for a disorder such as depression, where there are many variables, is recommended for future studies analyzing the possible modulation of certain factors such as the severity level and/or the chronicity of the disorder, the previous number of drug treatments, the presence of atypical depressive features, the variability of residual symptoms, and mostly, by the type of psychotherapy or antidepressant medication used, as well as the depressive disorder subtype. According to published economic evaluations, combination of antidepressants and psychotherapy is cost-effective in comparison to drugs alone. The economic model developed for the Spanish context showed that psychotherapy alone could be a cost-effective option although there is some degree of uncertainty.

Authors' methods: Systematic review (SR) on effectiveness. Electronic databases (Cochrane Library, CRD, Medline, Embase, CINAHL, PsycINFO) were reviewed since 1998 to July 2007; hand searching was also carried out. Selection criteria: 1) Designs: randomized clinical trials (RCTs) and SRs published in English or Spanish; 2) Interventions: selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs), cognitive therapy (CT), cognitive behavioural therapy (CBT) and interpersonal therapy (IPT); 3) Participants: adult patients with major depressive disorder (MDD) or dysthimia. Studies that fulfil criteria were reviewed and data were extracted by four reviewers; quality was assessed using the Jadad Scale to RCTs and the Oxman Scale to SRs. SR of economic evaluations published in Spanish or English until 2007. Electronic search was made in NHS EED and hand searching. Selection criteria: full economic evaluations that compare antidepressants, psychotherapy or a combination of both in patients with MDD (dysthimia was excluded). Studies that fulfil criteria were reviewed and data were extracted by an economist; quality was assessed using the Drummond et al. criteria. Economic evaluation. A decision tree was developed to compare paroxetine and CBT in patients with moderate MDD from the National Health System perspective and the societal perspective. The effectiveness data were obtained from a RCT and its follow-up study (DeRubeis 2005, Hollon 2005). The effectiveness measures were the quality adjusted life years (QALY) and the days free of depression (DFD). Direct health care costs (drugs, visits to general practitioner and visits to psychologist) and indirect costs were included in the analysis. Reference prices for drugs and public tariffs for visits were used. The incremental cost-effectiveness ratio (ICER) was estimated for the base case. A probabilistic sensitivity analysis was carries out.

Project Status: Completed

Year Published: 2010

URL for published report: https://sescs.es/farmacos-antidepresivos-y-tratamientos-psicologicos-para-los-trastornos-depresivos/

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