Lynch Frances L, Dickerson John F, Clarke Greg, Vitiello Benedetto, Porta Giovanna, Wagner Karen D, Emslie Graham, Asarnow Joan Rosenbaum, Keller Martin B, Birmaher Boris, Ryan Neal D, Kennard Betsy, Mayes Taryn, DeBar Lynn, McCracken James T, Strober Michael, Suddath Robert L, Spirito Anthony, Onorato Matthew, Zelazny Jamie, Iyengar Satish, Brent David
Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97212, USA.
Arch Gen Psychiatry. 2011 Mar;68(3):253-62. doi: 10.1001/archgenpsychiatry.2011.9.
Many youth with depression do not respond to initial treatment with selective serotonin reuptake inhibitors (SSRIs), and this is associated with higher costs. More effective treatment for these youth may be cost-effective.
To evaluate the incremental cost-effectiveness over 24 weeks of combined cognitive behavior therapy plus switch to a different antidepressant medication vs medication switch only in adolescents who continued to have depression despite adequate initial treatment with an SSRI.
Randomized controlled trial.
Six US academic and community clinics.
Three hundred thirty-four patients aged 12 to 18 years with SSRI-resistant depression.
Participants were randomly assigned to (1) switch to a different medication only or (2) switch to a different medication plus cognitive behavior therapy.
Clinical outcomes were depression-free days (DFDs), depression-improvement days (DIDs), and quality-adjusted life-years based on DFDs (DFD-QALYs). Costs of intervention, nonprotocol services, and families were included.
Combined treatment achieved 8.3 additional DFDs (P = .03), 0.020 more DFD-QALYs (P = .03), and 11.0 more DIDs (P = .04). Combined therapy cost $1633 more (P = .01). Cost per DFD was $188 (incremental cost-effectiveness ratio [ICER] = $188; 95% confidence interval [CI], -$22 to $1613), $142 per DID (ICER = $142; 95% CI, -$14 to $2529), and $78,948 per DFD-QALY (ICER = $78,948; 95% CI, -$9261 to $677,448). Cost-effectiveness acceptability curve analyses suggest a 61% probability that combined treatment is more cost-effective at a willingness to pay $100,000 per QALY. Combined treatment had a higher net benefit for subgroups of youth without a history of abuse, with lower levels of hopelessness, and with comorbid conditions.
For youth with SSRI-resistant depression, combined treatment decreases the number of days with depression and is more costly. Depending on a decision maker's willingness to pay, combined therapy may be cost-effective, particularly for some subgroups.
clinicaltrials.gov Identifier: NCT00018902.
许多患有抑郁症的青少年对选择性5-羟色胺再摄取抑制剂（SSRI）的初始治疗没有反应，这与更高的成本相关。对这些青少年更有效的治疗可能具有成本效益。
评估在24周内，对于那些尽管使用SSRI进行了充分的初始治疗但仍持续患有抑郁症的青少年，联合认知行为疗法并换用不同的抗抑郁药物与仅换用药物相比的增量成本效益。
随机对照试验。
美国的六家学术和社区诊所。
334名年龄在12至18岁之间的对SSRI耐药的抑郁症患者。
参与者被随机分配到（1）仅换用不同的药物或（2）换用不同的药物加认知行为疗法。
临床结局为无抑郁天数（DFD）、抑郁改善天数（DID）以及基于DFD的质量调整生命年（DFD-QALY）。纳入了干预、非方案服务和家庭的成本。
联合治疗多获得了8.3天的DFD（P = 0.03）、0.020个更多的DFD-QALY（P = 0.03）以及11.0天更多的DID（P = 0.04）。联合治疗的成本高出1633美元（P = 0.01）。每个DFD的成本为188美元（增量成本效益比[ICER] = 188美元；95%置信区间[CI]，-22美元至1613美元），每个DID为142美元（ICER = 142美元；95%CI，-14美元至2529美元），每个DFD-QALY为78,948美元（ICER = 78,948美元；95%CI，-9261美元至677,448美元）。成本效益可接受性曲线分析表明，在每QALY支付意愿为100,000美元时，联合治疗更具成本效益的概率为61%。联合治疗对没有虐待史、绝望程度较低以及有共病情况的青少年亚组具有更高的净效益。
对于对SSRI耐药的抑郁症青少年，联合治疗可减少抑郁天数且成本更高。根据决策者的支付意愿，联合治疗可能具有成本效益，特别是对于某些亚组。
clinicaltrials.gov标识符：NCT00018902。
