title: Modelling the cost-effectiveness of pharmacotherapy compared with cognitive-behavioural therapy and combination therapy for the treatment of moderate to severe depression in the UK.
abstract: BACKGROUND
  The National Institute of Health and Care Excellence (NICE) in England and Wales recommends the combination of pharmacotherapy and psychotherapy for the treatment of moderate to severe depression. However, the cost-effectiveness analysis on which these recommendations are based has not included psychotherapy as monotherapy as a potential option. For this reason, we aimed to update, augment and refine the existing economic evaluation.
  
  
  METHODS
  We constructed a decision analytic model with a 27-month time horizon. We compared pharmacotherapy with cognitive-behavioural therapy (CBT) and combination treatment for moderate to severe depression in secondary care from a healthcare service perspective. We reviewed the literature to identify relevant evidence and, where possible, synthesized evidence from clinical trials in a meta-analysis to inform model parameters.
  
  
  RESULTS
  The model suggested that CBT as monotherapy was most likely to be the most cost-effective treatment option above a threshold of £ 22,000 per quality-adjusted life year (QALY). It dominated combination treatment and had an incremental cost-effectiveness ratio of £ 20,039 per QALY compared with pharmacotherapy. There was significant decision uncertainty in the probabilistic and deterministic sensitivity analyses.
  
  
  CONCLUSIONS
  Contrary to previous NICE guidance, the results indicated that even for those patients for whom pharmacotherapy is acceptable, CBT as monotherapy may be a cost-effective treatment option. However, this conclusion was based on a limited evidence base, particularly for combination treatment. In addition, this evidence cannot easily be transferred to a primary care setting.
authors.affiliation: Institute of Psychiatry, King's College London,London,UK.
authors.forename: L
authors.initials: L
authors.lastname: Koeser
authors.affiliation: Department of Public Health and Community Medicine, Section of Psychiatry,University of Verona,Verona,Italy.
authors.forename: V
authors.initials: V
authors.lastname: Donisi
authors.affiliation: Institute of Psychiatry, King's College London,London,UK.
authors.forename: D P
authors.initials: DP
authors.lastname: Goldberg
authors.affiliation: Institute of Psychiatry, King's College London,London,UK.
authors.forename: P
authors.initials: P
authors.lastname: McCrone
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use*; D015928:Cognitive Behavioral Therapy / Q000191:economics*; D003131:Combined Modality Therapy / Q000379:methods*; D003362:Cost-Benefit Analysis; D003865:Major Depressive Disorder / Q000191:economics* / Q000628:therapy*; D004739:England; D006801:Humans; D008605:Mental Health Services / Q000191:economics*; D018803:Models, Economic; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014852:Wales
chemical_list: D000928:Antidepressive Agents
keywords: Antidepressants; National Institute of Health and Care Excellence; cognitive-behavioural therapy; cost-effectiveness analysis; depression