Relative cost-effectiveness of treatments for adolescent depression: 36-week results from the TADS randomized trial.

OBJECTIVE The cost-effectiveness of three active interventions for major depression in adolescents was compared after 36 weeks of treatment in the Treatment of Adolescents with Depression Study. METHOD Outpatients aged 12 to 18 years with a primary diagnosis of major depression participated in a randomized controlled trial conducted at 13 U.S. academic and community clinics from 2000 to 2004. Three hundred twenty-seven participants randomized to 1 of 3 active treatment arms, fluoxetine alone (n = 109), cognitive-behavioral therapy (n = 111) alone, or their combination (n = 107), were evaluated for a 3-month acute treatment and a 6-month continuation/maintenance treatment period. Costs of services received for the 36 weeks were estimated and examined in relation to the number of depression-free days and quality-adjusted life-years. Cost-effectiveness acceptability curves were also generated. Sensitivity analyses were conducted to assess treatment differences on the quality-adjusted life-years and cost-effectiveness measures. RESULTS Cognitive-behavioral therapy was the most costly treatment component (mean $1,787 [in monotherapy] and $1,833 [in combination therapy], median $1,923 [for both]). Reflecting higher direct and indirect costs associated with psychiatric hospital use, the costs of services received outside Treatment of Adolescents with Depression Study in fluoxetine-treated patients (mean $5,382, median $2,341) were significantly higher than those in participants treated with cognitive-behavioral therapy (mean $3,102, median $1,373) or combination (mean $2,705, median $927). Accordingly, cost-effectiveness acceptability curves indicate that combination treatment is highly likely (>90%) to be more cost-effective than fluoxetine alone at 36 weeks. Cognitive-behavioral therapy is not likely to be more cost-effective than fluoxetine. CONCLUSIONS These findings support the use of combination treatment in adolescents with depression over monotherapy.

[1]  Patrick Royston,et al.  Multiple Imputation of Missing Values: Update , 2005 .

[2]  R. Kessler,et al.  The costs and benefits of enhanced depression care to employers. , 2006, Archives of general psychiatry.

[3]  P. Rohde,et al.  Treatment for Adolescents with Depression Study (TADS): safety results. , 2006, Journal of the American Academy of Child and Adolescent Psychiatry.

[4]  K Claxton,et al.  The irrelevance of inference: a decision-making approach to the stochastic evaluation of health care technologies. , 1999, Journal of health economics.

[5]  Golda S. Ginsburg,et al.  Treatment for Adolescents With Depression Study (TADS): rationale, design, and methods. , 2003, Journal of the American Academy of Child and Adolescent Psychiatry.

[6]  J. Fairbank,et al.  The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. , 2007, Archives of general psychiatry.

[7]  Joseph L Schafer,et al.  Analysis of Incomplete Multivariate Data , 1997 .

[8]  B. Burns,et al.  Cost-effectiveness of treatments for adolescent depression: results from TADS. , 2008, The American journal of psychiatry.

[9]  J. Wing,et al.  Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) , 1999, British Journal of Psychiatry.

[10]  B. Vitiello,et al.  The Treatment for Adolescents with Depression Study (TADS): methods and message at 12 weeks. , 2006, Journal of the American Academy of Child and Adolescent Psychiatry.

[11]  P. Rohde,et al.  Functioning and quality of life in the Treatment for Adolescents with Depression Study (TADS). , 2006, Journal of the American Academy of Child and Adolescent Psychiatry.

[12]  P. Lelliott,et al.  Brief scale for measuring the outcomes of emotional and behavioural disorders in children , 1999, British Journal of Psychiatry.

[13]  Harold Alan Pincus,et al.  Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. , 2007, JAMA.

[14]  M. Sculpher,et al.  Decision Modelling for Health Economic Evaluation , 2006 .

[15]  J. Lave,et al.  Cost-effectiveness of treatments for major depression in primary care practice. , 1998, Archives of general psychiatry.

[16]  A Briggs,et al.  Confidence intervals or surfaces? Uncertainty on the cost-effectiveness plane. , 1998, Health economics.

[17]  Benedetto Vitiello,et al.  Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. , 2004, JAMA.

[18]  S. Markowitz,et al.  Suicidal Behavior and the Labor Market Productivity of Young Adults , 2005, SSRN Electronic Journal.

[19]  N. Perrin,et al.  Cost-effectiveness of an intervention to prevent depression in at-risk teens. , 2005, Archives of general psychiatry.

[20]  C. Sherbourne,et al.  Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. , 2001, JAMA.

[21]  Patricia A Brennan,et al.  Health outcomes related to early adolescent depression. , 2007, The Journal of adolescent health : official publication of the Society for Adolescent Medicine.

[22]  I. Goodyer,et al.  Cost-effectiveness of selective serotonin reuptake inhibitors and routine specialist care with and without cognitive–behavioural therapy in adolescents with major depression , 2007, British Journal of Psychiatry.

[23]  J. Coast,et al.  Quality-Adjusted Life-Years Lack Quality in Pediatric Care: A Critical Review of Published Cost-Utility Studies in Child Health , 2005, Pediatrics.

[24]  J. Endicott,et al.  Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire (PQ-LES-Q): reliability and validity. , 2006, Journal of the American Academy of Child and Adolescent Psychiatry.

[25]  B. O'brien,et al.  The death of cost-minimization analysis? , 2001, Health economics.

[26]  P. Yates,et al.  Child and adolescent mental health service use. HoNOSCA as an outcome measure. , 2000, The British journal of psychiatry : the journal of mental science.

[27]  B. Burns,et al.  Service Use and Costs of Care for Depressed Adolescents: Who Uses and Who Pays? , 2009, Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53.

[28]  M. Thase,et al.  Lost human capital from early-onset chronic depression. , 2000, The American journal of psychiatry.

[29]  N. Bilenberg.  Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) , 2003, European child & adolescent psychiatry.

[30]  J. Pyne,et al.  Depression-Free Day to Utility-Weighted Score: Is it Valid? , 2007, Medical care.

[31]  A. Briggs,et al.  Something old, something new, something borrowed, something blue: a framework for the marriage of health econometrics and cost-effectiveness analysis. , 2002, Health economics.

[32]  M. Knapp,et al.  QALYs and mental health care , 1997, Social Psychiatry and Psychiatric Epidemiology.

[33]  Peter A Ubel,et al.  What is the price of life and why doesn't it increase at the rate of inflation? , 2003, Archives of internal medicine.

[34]  Golda S. Ginsburg,et al.  The Treatment for Adolescents With Depression Study (TADS): demographic and clinical characteristics. , 2005, Journal of the American Academy of Child and Adolescent Psychiatry.

[35]  C. Essau,et al.  Depressive disorders in children and adolescents : epidemiology, risk factors, and treatment , 1999 .

[36]  D. Rubin,et al.  Statistical Analysis with Missing Data. , 1989 .

[37]  F. Lynch,et al.  Estimating the economic burden of depression in children and adolescents. , 2006, American journal of preventive medicine.

[38]  R. Kessler,et al.  Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers. , 2006, The American journal of psychiatry.