Adolescents with SSRI-resistant depression benefit from combined treatment of antidepressants and cognitive behaviour therapy

shutterstock_61626385 depressed teenage girl

Teenagers with depression sometimes do not respond to treatment with SSRI antidepressants and this inevitably leads to a higher cost of treatment.  This randomised controlled trial (conducted by researchers from Kaiser Permanente Northwest in Portland, Oregon) set out to evaluate the incremental cost-effectiveness over 24 weeks of combined cognitive behavior therapy plus switch to a different antidepressant medication vs medication switch only in adolescents who continued to have depression despite adequate initial treatment with an SSRI.

The study was conducted across 6 US academic and community clinics and involved 334 people aged 12 to 18 years with SSRI-resistant depression.  Participants were randomly assigned to:

  1. Switch to an alternative SSRI or venlafaxine only or
  2. Switch to an alternative SSRI or venlafaxine plus cognitive behavior therapy.

Clinical outcomes were:

  • Depression-free days (DFDs)
  • Depression-improvement days (DIDs), and
  • Quality-adjusted life-years based on DFDs (DFD-QALYs).

Costs of intervention, nonprotocol services, and families were included.

The RCT results showed that combined treatment with medication and CBT was more effective than medication alone:

  • Combined treatment achieved 8.3 additional DFDs (P = .03), 0.020 more DFD-QALYs (P = .03), and 11.0 more DIDs (P = .04).
  • Combined therapy cost $1,633 more (P = .01).
  • Cost per DFD was $188 (incremental cost-effectiveness ratio [ICER] = $188; 95% confidence interval [CI], -$22 to $1613), $142 per DID (ICER = $142; 95% CI, -$14 to $2,529), and $78,948 per DFD-QALY (ICER = $78,948; 95% CI, -$9,261 to $677,448).
  • Cost-effectiveness acceptability curve analyses suggest a 61% probability that combined treatment is more cost-effective at a willingness to pay $100,000 per QALY.
  • Combined treatment had a higher net benefit for subgroups of youth without a history of abuse, with lower levels of hopelessness, and with comorbid conditions.

The researchers concluded that:

For youth with SSRI-resistant depression, combined treatment decreases the number of days with depression and is more costly. Depending on a decision maker’s willingness to pay, combined therapy may be cost-effective, particularly for some subgroups.

Lynch FL, Dickerson JF, Clarke G, Vitiello B, Porta G, Wagner KD, Emslie G, Asarnow JR Jr, Keller MB, Birmaher B, Ryan ND, Kennard B, Mayes T, DeBar L, McCracken JT, Strober M, Suddath RL, Spirito A, Onorato M, Zelazny J, Iyengar S, Brent D. Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor-resistant depression: treatment of SSRI-resistant depression in adolescents trial findings. Arch Gen Psychiatry. 2011 Mar;68(3):253-62. [PubMed abstract]

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