• Frances L Lynch, John F Dickerson, Greg Clarke, Benedetto Vitiello, Giovanna Porta, Karen D Wagner, Graham Emslie, Joan Rosenbaum Asarnow, Martin B Keller, Boris Birmaher, Neal D Ryan, Betsy Kennard, Taryn Mayes, Lynn DeBar, James T McCracken, Michael Strober, Robert L Suddath, Anthony Spirito, Matthew Onorato, Jamie Zelazny, Satish Iyengar, and David Brent.
• Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97212, USA. frances.lynch@kpchr.org
• Arch. Gen. Psychiatry. 2011 Mar 1; 68 (3): 253-62.

ContextMany 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.ObjectiveTo 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.DesignRandomized controlled trial.SettingSix US academic and community clinics.PatientsThree hundred thirty-four patients aged 12 to 18 years with SSRI-resistant depression.InterventionParticipants were randomly assigned to (1) switch to a different medication only or (2) switch to a different medication plus cognitive behavior therapy.Main Outcome MeasuresClinical 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.ResultsCombined 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.ConclusionsFor 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.Trial Registrationclinicaltrials.gov Identifier: NCT00018902.

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