In univariate sensitivity analysis, we varied each individual model parameter over the ranges shown in Table 1 , and calculated cost-effectiveness outcomes at its upper and lower bounds. Prior research suggests that modeling probabilistic inputs independently may underestimate overall uncertainty.
Evidence-based pharmacotherapy of treatment-resistant unipolar depression.
Finally, in scenario sensitivity analysis, we assessed alternative approaches to modeling pharmacotherapy efficacy, depression cost, and maintenance ECT use. We next assessed incorporating an absolute mortality reduction of 0. To provide external validation of our model, we compared model-generated outcomes with independent published results.
Base case results are presented in Table 2. Over 4 years, ECT was projected to reduce the fraction of time with nonresponse of depression from These reductions translate to mean quality-adjusted survival gains of 0. Univariate sensitivity analysis results are shown in Figure 2. We used a decision analytic model to evaluate the clinical and economic effects of varying strategies for using ECT to treat treatment-resistant depression in the United States.
We found that ECT would substantially improve clinical outcomes, reducing time with uncontrolled depression from For patients with 3 or more prior treatment trials, offering ECT later in the course of treatment would still be cost-effective. When compared with other depression interventions that have been evaluated, the cost-effectiveness of ECT for treatment-resistant depression is superior to pharmacogenetic testing 41 and similar to a rural collaborative care intervention.
Similarly, the Florida best practice guidelines for treatment of major depressive disorder include ECT as a level 3 treatment, to be considered after failure of levels 1 and 2.
Treatment Resistant Depression: Be Brave Enough to Find the Solution! - Depression Alliance
Despite these recommendations, we recognize that many clinicians will regard offering ECT as third-line treatment to be overly aggressive, especially given the common view of ECT as a last-resort treatment for depression. By necessity, a model must include some simplifying assumptions.
Much of our cost data are more than a decade old and reflect primarily privately insured patients, 43 - 45 and there is uncertainty regarding the cost of ECT. Finally, the scope of our analysis introduces several limitations. Our choice of a health care sector perspective is intended to be relevant to patients, clinicians, and payers; however, this perspective excludes indirect costs and benefits such as patient transportation and productivity gains after depression treatment. In this mathematical modeling analysis, we found that ECT is a cost-effective treatment option for treatment-resistant depression in the United States.
Increasing use of ECT by offering it earlier in the course of treatment-resistant depression could greatly improve outcomes for this difficult-to-treat patient population. Corresponding Author: Eric L. Published Online: May 9, Author Contributions : Mr Ross had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Critical revision of the manuscript for important intellectual content: All authors. Conflict of Interest Disclosures: None reported. All Rights Reserved. Figure 1. View Large Download. Univariate Sensitivity Analysis Results. Table 1. Model States and Transitions eTable. Scenario Sensitivity Analysis Results.
Modern electroconvulsive therapy: vastly improved yet greatly underused. PubMed Google Scholar Crossref.
Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: a meta-analysis. Bipolar Disord.
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Related Pharmacotherapy for Depression and Treatment-resistant Depression
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