Cost-effectiveness of electroconvulsive therapy compared to repetitive transcranial magnetic stimulation for treatment-resistant severe depression: a decision model

• Published in: Psychological medicine 2015-05, Vol.45 (7), p.1459-1470
• Main Authors: Vallejo-Torres, L., Castilla, I., González, N., Hunter, R., Serrano-Pérez, P., Perestelo-Pérez, L.
• Format: Article
• Language: English
• Subjects: Combined Modality Therapy - economics; Comparative Effectiveness Research; Cost-Benefit Analysis; Decision making models; Decision Support Techniques; Depressive Disorder, Treatment-Resistant - economics; Depressive Disorder, Treatment-Resistant - therapy; Drug therapy; Electroconvulsive Therapy - economics; Electroconvulsive Therapy - methods; Humans; Magnetic fields; Markov chains; Mental depression; National Health Programs - economics; National Health Programs - statistics & numerical data; Original; Original Articles; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Sensitivity analysis; Spain; Therapy; Transcranial Magnetic Stimulation - economics; Transcranial Magnetic Stimulation - methods
• ISSN: 0033-2917; 1469-8978
• DOI: 10.1017/S0033291714002554

Electroconvulsive therapy (ECT) is widely applied to treat severe depression resistant to standard treatment. Results from previous studies comparing the cost-effectiveness of this technique with treatment alternatives such as repetitive transcranial magnetic stimulation (rTMS) are conflicting. We conducted a cost-effectiveness analysis comparing ECT alone, rTMS alone and rTMS followed by ECT when rTMS fails under the perspective of the Spanish National Health Service. The analysis is based on a Markov model which simulates the costs and health outcomes of individuals treated under these alternatives over a 12-month period. Data to populate this model were extracted and synthesized from a series of randomized controlled trials and other studies that have compared these techniques on the patient group of interest. We measure effectiveness using quality-adjusted life years (QALYs) and characterize the uncertainty using probabilistic sensitivity analyses. ECT alone was found to be less costly and more effective than rTMS alone, while the strategy of providing rTMS followed by ECT when rTMS fails is the most expensive and effective option. The incremental cost per QALY gained of this latter strategy was found to be above the reference willingness-to-pay threshold used in these types of studies in Spain and other countries. The probability that ECT alone is the most cost-effective alternative was estimated to be around 70%. ECT is likely to be the most cost-effective option in the treatment of resistant severe depression for a willingness to pay of €30,000 per QALY.