• Eric L Ross, Sandeep Vijan, Erin M Miller, Marcia Valenstein, and Kara Zivin.
• Harvard Medical School and Massachusetts General Hospital, Boston, and McLean Hospital, Belmont, Massachusetts (E.L.R.).
• Ann. Intern. Med. 2019 Dec 3; 171 (11): 785795785-795.

BackgroundMost guidelines for major depressive disorder recommend initial treatment with either a second-generation antidepressant (SGA) or cognitive behavioral therapy (CBT). Although most trials suggest that these treatments have similar efficacy, their health economic implications are uncertain.ObjectiveTo quantify the cost-effectiveness of CBT versus SGA for initial treatment of depression.DesignDecision analytic model.Data SourcesRelative effectiveness data from a meta-analysis of randomized controlled trials; additional clinical and economic data from other publications.Target PopulationAdults with newly diagnosed major depressive disorder in the United States.Time Horizon1 to 5 years.PerspectivesHealth care sector and societal.InterventionInitial treatment with either an SGA or group and individual CBT.Outcome MeasuresCosts in 2014 U.S. dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.Results Of Base Case AnalysisIn model projections, CBT produced higher QALYs (3 days more at 1 year and 20 days more at 5 years) with higher costs at 1 year (health care sector, $900; societal, $1500) but lower costs at 5 years (health care sector, -$1800; societal, -$2500).Results Of Sensitivity AnalysisIn probabilistic sensitivity analyses, SGA had a 64% to 77% likelihood of having an incremental cost-effectiveness ratio of $100 000 or less per QALY at 1 year; CBT had a 73% to 77% likelihood at 5 years. Uncertainty in the relative risk for relapse of depression contributed the most to overall uncertainty in the optimal treatment.LimitationLong-term trials comparing CBT and SGA are lacking.ConclusionNeither SGAs nor CBT provides consistently superior cost-effectiveness relative to the other. Given many patients' preference for psychotherapy over pharmacotherapy, increasing patient access to CBT may be warranted.Primary Funding SourceDepartment of Veterans Affairs, National Institute of Mental Health.

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