Format

Send to:

Choose Destination
See comment in PubMed Commons below
Lancet Psychiatry. 2016 Feb;3(2):137-44. doi: 10.1016/S2215-0366(15)00495-2. Epub 2016 Jan 7.

Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial.

Author information

  • 1Centre for Academic Mental Health, University of Bristol, Bristol, UK. Electronic address: nicola.wiles@bristol.ac.uk.
  • 2Centre for Academic Mental Health, University of Bristol, Bristol, UK.
  • 3Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK.
  • 4Primary Care Research Group, University of Exeter Medical School, Exeter, UK.
  • 5Centre for Academic Primary Care, University of Bristol, Bristol, UK.
  • 6Department of Psychiatry, University of Oxford, Oxford, UK.
  • 7Division of Psychiatry, University College London, London, UK.
  • 8Institute of Health and Wellbeing, General Practice and Primary Care Group, University of Glasgow, Glasgow, Scotland, UK.
  • 9Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, Scotland, UK.
  • 10School of Social and Community Medicine and School of Clinical Sciences, University of Bristol, Bristol, UK.

Abstract

BACKGROUND:

Cognitive behavioural therapy (CBT) is an effective treatment for people whose depression has not responded to antidepressants. However, the long-term outcome is unknown. In a long-term follow-up of the CoBalT trial, we examined the clinical and cost-effectiveness of cognitive behavioural therapy as an adjunct to usual care that included medication over 3-5 years in primary care patients with treatment-resistant depression.

METHODS:

CoBalT was a randomised controlled trial done across 73 general practices in three UK centres. CoBalT recruited patients aged 18-75 years who had adhered to antidepressants for at least 6 weeks and had substantial depressive symptoms (Beck Depression Inventory [BDI-II] score ≥14 and met ICD-10 depression criteria). Participants were randomly assigned using a computer generated code, to receive either usual care or CBT in addition to usual care. Patients eligible for the long-term follow-up were those who had not withdrawn by the 12 month follow-up and had given their consent to being re-contacted. Those willing to participate were asked to return the postal questionnaire to the research team. One postal reminder was sent and non-responders were contacted by telephone to complete a brief questionnaire. Data were also collected from general practitioner notes. Follow-up took place at a variable interval after randomisation (3-5 years). The primary outcome was self-report of depressive symptoms assessed by BDI-II score (range 0-63), analysed by intention to treat. Cost-utility analysis compared health and social care costs with quality-adjusted life-years (QALYs). This study is registered with isrctn.com, number ISRCTN38231611.

FINDINGS:

Between Nov 4, 2008, and Sept 30, 2010, 469 eligible participants were randomised into the CoBalT study. Of these, 248 individuals completed a long-term follow-up questionnaire and provided data for the primary outcome (136 in the intervention group vs 112 in the usual care group). At follow-up (median 45·5 months [IQR 42·5-51·1]), the intervention group had a mean BDI-II score of 19·2 (SD 13·8) compared with a mean BDI-II score of 23·4 (SD 13·2) for the usual care group (repeated measures analysis over the 46 months: difference in means -4·7 [95% CI -6·4 to -3·0, p<0·001]). Follow-up was, on average, 40 months after therapy ended. The average annual cost of trial CBT per participant was £343 (SD 129). The incremental cost-effectiveness ratio was £5374 per QALY gain. This represented a 92% probability of being cost effective at the National Institute for Health and Care Excellence QALY threshold of £20 000.

INTERPRETATION:

CBT as an adjunct to usual care that includes antidepressants is clinically effective and cost effective over the long-term for individuals whose depression has not responded to pharmacotherapy. In view of this robust evidence of long-term effectiveness and the fact that the intervention represented good value-for-money, clinicians should discuss referral for CBT with all those for whom antidepressants are not effective.

FUNDING:

National Institute for Health Research Health Technology Assessment.

Copyright © 2016 Wiles et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.

PMID:
26777773
[PubMed - in process]
Free full text
PubMed Commons home

PubMed Commons

0 comments
How to join PubMed Commons

    Supplemental Content

    Full text links

    Icon for Elsevier Science
    Loading ...
    Write to the Help Desk