番茄社区

Electroconvulsive therapy (ECT) is efficacious and also cost effective for patients with treatment-resistant major depression, and it should be considered after failure of two prior trials of pharmacotherapy and/or psychotherapy, new research suggests.

When researchers from the University of Michigan Department of Psychiatry constructed a decision analytic model to simulate the clinical and economic impact of ECT in patients who had not responded to drugs or psychotherapy, they found the treatment to be associated with improved clinical outcomes and a reduction in time having uncontrolled depression.

The analysis, published online in, suggests that offering ECT after failure of two lines of pharmacotherapy and/or psychotherapy would "most reliably maximize ECT's health-economic value."

The study's lead researcher, Eric L. Ross, explained that among clinicians familiar with ECT, there is far less stigma surrounding the treatment than among the public: "Psychiatrists know that this is a very effective treatment, but it is still not widely used," he told 番茄社区. "Among providers, a big barrier to treatment is cost. There is a perception that ECT is cost prohibitive. The question we were trying to answer is, 'Is it worth the cost?'"

The team used data from recent studies to create a simulation model that integrated information on clinical efficacy, costs, and quality-of-life effects of ECT compared with pharmacotherapy/psychotherapy during a 4-year horizon.

Seven strategies were simulated, including a strategy with no ECT and six other simulations with 0 to 5 treatment courses prior to ECT.

From these simulations, the researchers calculated overall quality-adjusted life years (QALYs) and costs from a healthcare sector perspective. The main outcomes measured were remission, response, and nonresponse of depression; QALY; costs in 2013 U.S. dollars; and incremental cost-effectiveness ratios (ICERs). Strategies with ICERs of $100,000 per QALY or less were considered to be cost effective.

Among the main findings were the following:

• Over 4 years, ECT was projected to reduce time with uncontrolled depression from 50% of life-years to 33% to 37% of life-years, with greater improvements when ECT is offered earlier

• Mean healthcare costs were increased by $7,300 to $12,000, with greater incremental costs when ECT was offered earlier

• In the base case, third-line ECT was cost-effective, with an ICER of $54,000 per QALY. Third-line ECT remained cost-effective in a range of univariate, scenario, and probabilistic sensitivity analyses

"Incorporating all input data uncertainty, we estimate a 74% to 78% likelihood that at least one of the ECT strategies is cost effective and a 56% to 58% likelihood that third-line ECT is the optimal strategy," the researchers wrote.

"'Cost effective' does not mean 'cost saving,'" Ross said. "But what this study tells us is that the additional money spent for this treatment seems to be worth it, in terms of health benefits."

ECT treatments cost $300 to $1,000 per treatment, with an initial course requiring five to 15 treatments followed by 10 to 20 maintenance treatments per year, the researchers noted. That means the annual cost can be more than $10,000, compared with a cost of several hundred dollars for many antidepressant medications.

"Right now ECT is commonly regarded as a last-resort treatment for people who have tried many other treatments," Ross said, adding that in one analysis the typical ECT patient had been on seven prior antidepressants.

Study limitations cited by the researchers included the necessity of relying on simplifying assumptions in the model, and that there were shortcomings in the data used in the model. "Much of our cost data are more than a decade old and reflect primarily privately insured patients, and there is uncertainty regarding the cost of ECT. In addition, many of our estimates of relapse rates with pharmacotherapy or maintenance ECT reflect sample sizes of 100 or fewer patients. Finally, our reliance on clinical trial data may limit the generalizability and external validity of our results. However, our main findings are robust to sensitivity analysis using alternative data sources or appropriately broad confidence intervals."

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