Health Economics Study from Singapore: Cost-Effectiveness of ECT

Out on PubMed, from researchers in Singapore, is this study:

Neurostimulation therapies in major depressive disorder: A decision-analytic model.

Teng M, Khoo AL, Zhao YJ, Abdin E, Mok YM, Lim BP, Tor PC.Early Interv Psychiatry. 2020 Nov 30. doi: 10.1111/eip.13091. Online ahead of print.PMID: 33254283

The abstract is copied below:

Aim: Neurostimulation techniques are effective treatments for major depressive disorders (MDD). However, the optimal sequence of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) as part of antidepressant treatment algorithm is unclear. We examined the cost-effectiveness of ECT and TMS in MDD.

Methods: A decision-analytic model was developed to determine total costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) for 10 strategies. Each strategy comprised four treatment lines with ECT and TMS incorporated as second, third, or fourth line. A scenario analysis that explored the cost-effectiveness of maintenance approach by continuing ECT and TMS after acute treatment was performed.

Results: In the base case, fourth-line TMS after three preceding trials of antidepressants was least costly at US$ 5523 yielding 1.424 QALYs. Compared with this strategy, fourth-line ECT and third-line TMS followed by ECT were cost-effective with ICERs of US$ 7601 per QALY gained and US$ 11 388 per QALY gained, respectively. In the scenario analysis where continuation treatments of ECT and TMS were provided, third-line TMS followed by ECT was cost-effective, with an ICER of US$ 17 198 per QALY gained. Effectiveness of ECT and cost of managing severe depression were influential parameters affecting the cost-effectiveness results.

Conclusions: In acute treatment of MDD, fourth-line ECT was the most cost-effective strategy. In maintenance treatment, the strategy that incorporated third-line TMS and fourth-line ECT was cost-effective. The overall findings confirmed the value of neurostimulation therapies which should be offered early in the process of managing depression.

Keywords: antidepressant; electroconvulsive therapy; major depressive disorder; neurostimulation; transcranial magnetic stimulation.

A Table, a Figure, and an excerpt from the text:

               In the scenario analysis where patients were switched to either

               ECT or TMS after one trial of antidepressant, ECT was cost-effective

               with an ICER of US$ 40 872 per QALY gained when compared with

               all-medication strategy. As a third-line treatment, both ECT and TMS

               were cost-effective relative to all-medication strategy with ICER

               values of US$ 9963 per QALY gained and US$ 12 081 per QALY

               gained respectively. Further to a fourth-line of treatment, ECT was

               the dominating strategy with an ICER of US$ 7601 per QALY gained.

               ...our analysis demonstrated that initiating ECT as early as a fourth-line

                treatment was considered to be cost-effective, dominating other

                strategies. Our work sets itself apart from this study (Ross

                et al., 2018) by including TMS as an option in the various strategies

                either independently or sequentially with ECT. Furthermore, we also

                incorporated the indirect cost of productivity loss. Instead of applying

                one single remission rate or response rate for ECT and TMS at different

                steps of treatment, the clinical effectiveness data of our analysis

                was derived from a real-world population analysis which captured

                number of failed antidepressant trials.

This is a highly sophisticated health economics study; health economics mavens will want to read it carefully in its entirety (~30 minutes). For normal clinicians and typical academics (myself included), details of the methodology and mathematics used will be difficult to understand fully. Nonetheless, many of the important concepts are graspable.

Cost effectiveness is one factor in assessing the public health impact of treatments. However, in my opinion, paradigms with both TMS and ECT are fraught because they blur the lines between these two very different modalities. ECT stands alone as the most effective acute treatment for severe mood and psychotic disorders; mixing it in with "neurostimulation" therapies normalizes these juxtapositions, possibly to the detriment of patients with the most urgent clinical situations.

That aside, this study adds to the evidence base of ECT as cost-effective standard treatment, with major public health significance. 

This article alerts us to the existence of the journal, Early Intervention in Psychiatry.

The authors are to be congratulated for their very meticulous contribution to the medical literature on depression treatment.