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Original Investigation
July 2018

Cost-effectiveness of Electroconvulsive Therapy vs Pharmacotherapy/Psychotherapy for Treatment-Resistant Depression in the United States

Author Affiliations
  • 1Department of Psychiatry, University of Michigan Medical School, Ann Arbor
  • 2Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
  • 3Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor
  • 4Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor
JAMA Psychiatry. 2018;75(7):713-722. doi:10.1001/jamapsychiatry.2018.0768
Key Points

Question  What is the cost-effectiveness of electroconvulsive therapy compared with antidepressant medications and/or psychotherapy for treatment-resistant major depressive disorder in the United States?

Findings  In this mathematical modeling analysis integrating data from multiple published sources, offering electroconvulsive therapy as third-line treatment for depression would cost an estimated $54 000 per quality-adjusted life-year gained. Over 4 years, this would reduce time with uncontrolled depression from 50% to 34% of life-years.

Meaning  Electroconvulsive therapy may be an effective and cost-effective treatment for treatment-resistant depression and should be considered after failure of 2 or more lines of pharmacotherapy and/or psychotherapy.


Importance  Electroconvulsive therapy (ECT) is a highly effective treatment for depression but is infrequently used owing to stigma, uncertainty about indications, adverse effects, and perceived high cost.

Objective  To assess the cost-effectiveness of ECT compared with pharmacotherapy/psychotherapy for treatment-resistant major depressive disorder in the United States.

Design, Setting, and Participants  A decision analytic model integrating data on clinical efficacy, costs, and quality-of-life effects of ECT compared with pharmacotherapy/psychotherapy was used to simulate depression treatment during a 4-year horizon from a US health care sector perspective. Model input data were drawn from multiple meta-analyses, randomized trials, and observational studies of patients with depression. Where possible, data sources were restricted to US-based studies of nonpsychotic major depression. Data were analyzed between June 2017 and January 2018.

Interventions  Six alternative strategies for incorporating ECT into depression treatment (after failure of 0-5 lines of pharmacotherapy/psychotherapy) compared with no ECT.

Main Outcomes and Measures  Remission, response, and nonresponse of depression; quality-adjusted life-years; costs in 2013 US dollars; and incremental cost-effectiveness ratios. Strategies with incremental cost-effectiveness ratios of $100 000 per quality-adjusted life-year or less were designated cost-effective.

Results  Based on the Sequenced Treatment Alternatives to Relieve Depression trial, we simulated a population with a mean (SD) age of 40.7 (13.2) years, and 62.2% women. Over 4 years, ECT was projected to reduce time with uncontrolled depression from 50% of life-years to 33% to 37% of life-years, with greater improvements when ECT is offered earlier. Mean health care costs were increased by $7300 to $12 000, with greater incremental costs when ECT was offered earlier. In the base case, third-line ECT was cost-effective, with an ICER of $54 000 per quality-adjusted life-year. Third-line ECT remained cost-effective in a range of univariate, scenario, and probabilistic sensitivity analyses. Incorporating all input data uncertainty, we estimate a 74% to 78% likelihood that at least 1 of the ECT strategies is cost-effective and a 56% to 58% likelihood that third-line ECT is the optimal strategy.

Conclusions and Relevance  For US patients with treatment-resistant depression, ECT may be an effective and cost-effective treatment option. Although many factors influence the decision to proceed with ECT, these data suggest that, from a health-economic standpoint, ECT should be considered after failure of 2 or more lines of pharmacotherapy/psychotherapy.