Cost-utility Analysis of Esketamine and ECT in Adults with Treatment-resistant Depression
Out on PubMed, from investigators in Sweden, is this study:
Cost-utility analysis of esketamine and electroconvulsive therapy in adults with treatment-resistant depression.
The abstract is copied below:
Background: Electroconvulsive therapy (ECT) has long been used for treating individuals with treatment-resistant depression (TRD). Esketamine has recently emerged as a new treatment for TRD due to its rapid antidepressant effects. To further inform the decision regarding choice of treatment, this paper aims to evaluate whether ECT or esketamine is the more cost-effective option.
Methods: The cost-effectiveness was derived as cost per quality-adjusted life-year (QALY) using a Markov model from a societal and life-time perspective. The incremental cost-effectiveness ratio (ICER) was calculated. Health states included different depression and remission states and death. Data to populate the model was derived from randomised controlled trials and other research. Various sensitivity analyses were carried out to test the robustness of the model.
Results: The base case scenario shows that ECT is cost-effective compared to esketamine and yields more QALYs at a lower cost. The sensitivity analysis shows that ECT is cost-effective in all scenarios and ECT dominates esketamine in 12 scenarios.
Conclusions: This study found that, from a cost-effectiveness point of view, ECT should be the first-hand option for individuals with TRD, when other first line treatments have failed. Considering the lack of economic evaluation of ECT and esketamine, this study is of great value to decision makers.
Keywords: Cost-effectiveness; Electroconvulsive therapy; Esketamine; ICER; Markov model; QALY; Treatment-resistant depression.
Discussion
This is, to our knowledge, the first study that evaluates whether ECT or esketamine is to recommend from a cost-effectiveness perspective among individuals with TRD. The base case from the main model indicated that ECT is cost-effective compared with esketamine. The results show that the absolute cost of ECT is slightly lower than the cost for esketamine and ECT generates more QALYs. Results from the sensitivity analyses demonstrate the robustness of these findings. There were some changes to the ICER, but all the sensitivity analyses resulted in ECT being cost-effective compared with esketamine. The results from the maintenance model with M-ECT somewhat supports these finding.
Conclusion
This study found that, from a cost-effectiveness point of view, ECT should be the first-hand option for individuals with TRD, when other first line treatments have failed. The time horizon did not change the estimates noteworthy and there was no scenario in the main model where esketamine was cost-effective. Nonetheless, esketamine could potentially be an option for individuals not able to undergo ECT. Further research regarding potential subgroups of individuals where esketamine treatment could be cost-effective is warranted. Considering the lack of economic evaluation of ECT and esketamine, this study is of great value to decision makers.
This is a very interesting health economics study from Swedish authors using a UK healthcare setting. The finding of ECT being so cost effective compared to esketamine is quite remarkable. If the underlying assumptions used in the study are valid, then the authors' closing statement that the findings are "of great value to decision makers" is correct.
Despite some unedited language mistakes, the paper reads well and makes many of the complex issues in this type of analysis easy to understand. Interestingly, the authors point out the negative perspective on maintenance ECT in the NICE guidelines, and make adjustments for the more accepting perspective (with strong data) in countries other than the UK.
A full read, ~25 minutes, will be rewarding for most ECT practitioners.
The analytic approach to the data in this study is beyond my simple understanding of statistics, but the conclusions are clear enough. The advent of rTMS and esketamine has created some (avoidable) confusion in the minds of some psychiatrists as to when to turn to ECT versus rTMS versus esketamine/ketamine for severe depressive illness. This paper goes a long way to assuring practitioners that ECT is the unqualified "winner" compared against esketamine. Fortunately most psychiatrists seem to have already received the message - I recently saw a poster created by Janssen Pharmaceuticals looking at "real-world" usage of ECT versus esketamine to address suicide risk. ECT was used in far more cases as compared with esketamine to address suicide risk.
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