Is ECT Cost-effective? A Critique of the National Institute of Health and Clinical Excellence's Report on the Economic Analysis of ECT

Abstract: The report of the National Institute of Health and Clinical Excellence (NICE) on the economic analysis of electroconvulsive therapy (ECT) concludes that ECT and pharmacotherapy are "likely to be equally cost-effective" in the treatment of major depression. However, this economic analysis is acknowledged by the NICE report to be "crude and based on a number of uncertain assumptions." An evaluation by the Health Technology Assessment Committee of the National Coordinating Centre for Health Technology Assessment, commissioned and funded on behalf of NICE, provides a detailed cost comparison of ECT and pharmacotherapy in the treatment of major depression [Greenhalgh, Health Technol Assess, 9 (9) (2005) 1-156]. The Health Technology Assessment Committee analyzed data from separate studies of the efficacy of antidepressants and ECT. However, these data included few randomized controlled trials directly comparing the cost-effectiveness of ECT and medication in treatment-resistant depression. In the limited number of trials included in the report, there was a bias in favor of medication. For example, compared with the antidepressant trials, the ECT trials included more patients who had comorbid psychosis and treatment-resistant depression and would therefore have a more difficult treatment of depression. The Committee also evaluated data to determine that the relapse rate after pharmacological treatment is approximately 3 times the relapse rate after ECT. Although the report provides a format for analyzing the cost-effectiveness of ECT and recommends future directions for research, the conclusions reached by the Committee are relatively limited and should not be used as a template for future public policy.