Are psychological treatments for depression in primary care cost-effective?
BACKGROUND
Depression is a highly prevalent condition that is associated with high levels of work absenteeism and high health care costs. Most patients are treated in primary care. A large group of patients prefers psychological treatments to antidepressants.


OBJECTIVE
To systematically review the evidence for the cost-effectiveness of psychological treatments, psychotherapy and counselling, in comparison with usual care or antidepressant treatment in adult primary care patients with depression.


METHODS
A computer-assisted search of MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library was carried out. Two independent reviewers selected studies for the review, extracted data and assessed the methodological quality of the included studies.


RESULTS
Seven studies were included in the review. Forms of psychotherapy that were evaluated were cognitive behavioural therapy, interpersonal psychotherapy and couple therapy. Usual care generally consisted of care as usually provided by the general practitioner. No conclusion can be drawn on the cost-effectiveness of the above mentioned forms of psychotherapy in comparison with usual care or antidepressant treatment. The cost-effectiveness of counselling in comparison with usual care and antidepressant therapy is yet to be established. Meta-analyses showed that psychotherapy was significantly more expensive than usual care, but not significantly more expensive than antidepressant treatment. Counselling was associated with no statistically significant differences in costs and effects in comparison with usual care in the pooled analysis.


CONCLUSIONS
Based on this review, no firm conclusions on the cost-effectiveness of psychotherapy and counselling in primary care can be drawn. Most studies had methodological shortcomings, which limit the generalisibility of the results.


CONCLUSIONS
Given the reluctance of patients to use antidepressants and the large economic impact of depression, policy makers have a need for well designed and sufficiently powered economic evaluations of psychological treatments. The available evidence seems to indicate that psychotherapy has more substantial clinical effects than counselling. Therefore, the emphasis should be on economic evaluations of forms of psychotherapy that have proved to be clinically effective.


CONCLUSIONS
There are indications that the cost-effectiveness of depression treatment on the whole may be improved by incorporating psychological treatments into enhanced care models, tailored to the needs of individual patients and/or by providing them by trained nurses instead of psychologists or psychotherapists. Further research should investigate these patient tailored, stepped care treatment modalities for depression treatment.
Bosmans
Judith E
JE
Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands. judith.bosmans@falw.vu.nl
van Schaik
Digna J F
DJ
de Bruijne
Martine C
MC
van Hout
Hein P J
HP
van Marwijk
Harm W J
HW
van Tulder
Maurits W
MW
Stalman
Wim A B
WA
D000328:Adult; D000928:Antidepressive Agents / Q000191:economics* / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003866:Depressive Disorder / Q000191:economics / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D011613:Psychotherapy / Q000191:economics*
D000928:Antidepressive Agents