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Original Investigation
November 2016

The Costs and Cost-effectiveness of Collaborative Care for Adolescents With Depression in Primary Care SettingsA Randomized Clinical Trial

Author Affiliations
  • 1Department of Pediatrics, University of Washington School of Medicine, Seattle
  • 2Seattle Children’s Research Institute Center for Child Health, Behavior, and Development, Seattle, Washington
  • 3Group Health Research Institute, Seattle, Washington
  • 4Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
JAMA Pediatr. 2016;170(11):1048-1054. doi:10.1001/jamapediatrics.2016.1721
Key Points

Question  The Reaching Out to Adolescents in Distress (ROAD) collaborative care model has been found to be effective in treating adolescent major depressive disorder, but is it cost-effective?

Findings  A randomized clinical trial conducted at 9 primary care clinics in Washington State suggests that collaborative care results in an increase of 0.04 quality-adjusted life-year over usual care at $883 above usual care, for a mean incremental cost-effectiveness ratio of $18 239 per quality-adjusted life-year gained.

Meaning  Even by the most conservative standards, the ROAD collaborative care model is a cost-effective approach for treating adolescent depression.

Abstract

Importance  Depression is one of the most common adolescent chronic health conditions and can lead to increased health care use. Collaborative care models have been shown to be effective in improving adolescent depressive symptoms, but there are few data on the effect of such a model on costs.

Objective  To evaluate the costs and cost-effectiveness of a collaborative care model for treatment of adolescent major depressive disorder in primary care settings.

Design, Setting, and Participants  This randomized clinical trial was conducted between April 1, 2010, and April 30, 2013, at 9 primary care clinics in the Group Health system in Washington State. Participants were adolescents (age range, 13-17 years) with depression who participated in the Reaching Out to Adolescents in Distress (ROAD) collaborative care intervention trial.

Interventions  A 12-month collaborative care intervention included an initial in-person engagement session, delivery of evidence-based treatments, and regular follow-up by master’s level clinicians. Youth in the usual care control condition received depression screening results and could access mental health services and obtain medications through Group Health.

Main Outcomes and Measures  Cost outcomes included intervention costs and per capita health plan costs, calculated from the payer perspective using administrative records. The primary effectiveness outcome was the difference in quality-adjusted life-years (QALYs) between groups from baseline to 12 months. The QALYs were calculated using Child Depression Rating Scale–Revised scores measured during the clinical trial. Cost and QALYs were used to calculate an incremental cost-effectiveness ratio.

Results  Of those screened, 105 youths met criteria for entry into the study, and 101 were randomized to the intervention (n = 50) and usual care (n = 51) groups. Overall health plan costs were not significantly different between the intervention ($5161; 95% CI, $3564-$7070) and usual care ($5752; 95% CI, $3814-$7952) groups. Intervention delivery cost an additional $1475 (95% CI, $1230-$1695) per person. The intervention group had a mean daily utility value of 0.78 (95% CI, 0.75-0.80) vs 0.73 (95% CI, 0.71-0.76) for the usual care group. The net mean difference in effectiveness was 0.04 (95% CI, 0.02-0.09) QALY at $883 above usual care. The mean incremental cost-effectiveness ratio was $18 239 (95% CI, dominant to $24 408) per QALY gained, with dominant indicating that the intervention resulted in both a net cost savings and a net increase in QALYs.

Conclusions and Relevance  Collaborative care for adolescent depression appears to be cost-effective, with 95% CIs far below the strictest willingness-to-pay thresholds. These findings support the use of collaborative care interventions to treat depression among adolescent youth.

Trial Registration  clinicaltrials.gov Identifier: NCT01140464

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