Third-line ECT May Be Cost-Effective for US Patients With Depression

By Marilynn Larkin

NEW YORK—Third-line electroconvulsive therapy (ECT) may be both effective and cost-effective for US patients with treatment-resistant depression, researchers say.

While "highly effective" for depression, ECT is not used often because of stigma, uncertainty about when to use it, adverse effects and perceived high costs, according to Eric Ross of the University of Michigan Medical School in Ann Arbor and colleagues.

To assess its cost-effectiveness in the US healthcare system, the team used a mathematical model that integrated data on clinical efficacy, costs, and quality of life to simulate treatment over four years. Data were drawn from meta-analyses, randomized trials and observational studies of patients with major depression.

For the study, a simulated cohort of patients (mean age, 40.7; 62.2% women) initiated first-line treatment for depression and progressed through six alternative strategies for incorporating ECT (after failure of 0-5 lines of pharmacotherapy/psychotherapy) compared with no ECT.

The first month of ECT treatment included eight sessions; maintenance treatments were varied from 16 to 25 per year in the sensitivity analyses.

As reported online May 9 in JAMA Psychiatry, ECT was projected to reduce time with uncontrolled depression from 50% of life-years to 33%-37% of life-years over four years, with greater improvements when ECT was offered earlier.

Mean health care costs were increased by $7,300 to $12,000, with greater incremental costs when ECT was offered earlier. Cost increases were mainly due to the cost of ECT; mean ECT-related costs increased from $9,100 to $17,100 with earlier ECT, while the mean cost of other health care declined from $42,500 without ECT to $37,400 with first-line ECT.

Using a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY), third-line ECT (i.e., offering ECT after two treatment failures) was projected to be cost-effective, with an incremental cost-effectiveness ratio (ICER) of $54,000 per QALY.

Second- and first-line ECT were not cost-effective, and fourth-, fifth- and sixth-line ECT offered fewer QALYs at a worse ICER than other strategies. However, compared with not offering ECT, fourth, fifth- and sixth-line ECT would be cost-effective, with ICERs between $60,000-$70,000 per QALY.

"Incorporating all input data uncertainty, we estimate a 74% to 78% likelihood that at least one of the ECT strategies is cost-effective and a 56% to 58% likelihood that third-line ECT is the optimal strategy," the authors state.

"I do hope that this study will change practice," Ross said in an email to Reuters Health. "Currently, ECT is often regarded as a 'last resort' therapy for depression, offered only to patients who have previously tried 5-10 prior medications and psychotherapies without success."

"A primary contribution of our work is providing clinicians a fairly clear threshold for when ECT should be considered for treatment-resistant depression," he said. "My hope is that by clarifying this indication, clinicians will feel more comfortable in offering ECT to those patients who could benefit from it."

Dr. Michael J. Vergare, The Daniel Lieberman Professor and Chair in the Department of Psychiatry and Human Behavior at Sidney Kimmel Medical College in Philadelphia, commented, "The study is important because it took a unique, mathematical model to project response and costs based on six different strategies."

"It looks at a broad population and is able to show through modeling that while there are significant costs associated ECT, there are also costs - financial and personal - associated with prolonged pharmacotherapy/psychotherapy for those who do not respond," he told Reuters Health by email. "ECT for this subgroup was more effective and provided better relief of symptoms."

"The study raises the importance of earlier identification of patients who do not respond to 'usual' treatment with pharmacotherapy/psychotherapy," he added. "An additional note that I didn’t see specified in the article is that ECT can be initiated in a hospital setting, but is sometimes followed up with periodic outpatient treatments."

SOURCE: https://bit.ly/2Gecayx

JAMA Psychiatry 2018.

(c) Copyright Thomson Reuters 2018. Click For Restrictions - https://agency.reuters.com/en/copyright.html