Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents.
OBJECTIVE
To assess from a health sector perspective the incremental cost-effectiveness of cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of major depressive disorder (MDD) in children and adolescents, compared to "current practice".


METHODS
The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analysis of randomised controlled trials. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are tracked for the duration of a new episode of MDD arising in eligible children (age 6-17 years) in the Australian population in the year 2000. Simulation-modelling techniques are used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratios.


RESULTS
Compared to current practice, CBT by public psychologists is the most cost-effective intervention for MDD in children and adolescents at A$9000 per DALY saved (95% UI A$3900 to A$24 000). SSRIs and CBT by other providers are less cost-effective but likely to be less than A$50 000 per DALY saved (> 80% chance). CBT is more effective than SSRIs in children and adolescents, resulting in a greater total health benefit (DALYs saved) than could be achieved with SSRIs. Issues that require attention for the CBT intervention include equity concerns, ensuring an adequate workforce, funding arrangements and acceptability to various stakeholders.


CONCLUSIONS
Cognitive behavioural therapy provided by a public psychologist is the most effective and cost-effective option for the first-line treatment of MDD in children and adolescents. However, this option is not currently accessible by all patients and will require change in policy to allow more widespread uptake. It will also require "start-up" costs and attention to ensuring an adequate workforce.
Health Surveillance and Evaluation Section, Public Health, Department of Human Services, Melbourne, Australia. michelle.haby@dhs.vic.gov.au
Michelle M
MM
Haby
Bruce
B
Tonge
Lyn
L
Littlefield
Rob
R
Carter
Theo
T
Vos
D000293:Adolescent; D001315:Australia; D002648:Child; D015928:Cognitive Behavioral Therapy / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D003865:Major Depressive Disorder / Q000188:drug therapy / Q000191:economics* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000191:economics*; D010349:Patient Compliance / Q000706:statistics & numerical data; D017367:Selective Serotonin Reuptake Inhibitors / Q000191:economics*
D017367:Selective Serotonin Reuptake Inhibitors