A Cost-Effectiveness Analysis of Cognitive Behavior Therapy and Fluoxetine (Prozac) in the Treatment of Depression DAVID O. ANTONUCCIO
University of Nevada School of Medicine and Reno V.A. Medical Center (116B2) MICHAEL THOMAS
University of Nevada Dept. of Accounting and CIS
WILLIAM G. DANTON
University of Nevada School of Medicine and Reno EA. Medical Center/(116B2) Depression affects at least 11 million Americans per year and costs the U.S. economy an estimated 44 billion dollars annually. Comprehensive review of the existing scientific evidence suggests that psychotherapy, particularly cognitive behavior therapy (CBT), is at least as effective as medication in the treatment of depression, even if severe (Antonuccio, Danton, & DeNelsky, 1995). These conclusions hold for both vegetative and social adjustment symptoms, especially when patient-rated measures are used and long-term follow-up is considered. In addition, several well-controlled studies with long-term follow-up (Evans et al., 1992; Shea et al., 1992; Simons, Murphy, Levine, & Wetzel, 1986) suggest that CBT may be more effective than drug treatment at preventing relapse. The relative effectiveness of psychotherapy for depression, particularly CBT, has been reinforced by meta-analyses reported in both psychiatry (Hollon, Shelton, & Loosen, 1991; Wexler & Cicchetti, 1992) and psychology journals (Dobson, 1989; Robinson, Berman, & Neimeyer, 1990; Steinbrueck, Maxwell, & Howard, 1983). In the era of managed care, it fs not enough to be effective; treatments must be cost-effective. This paper considers the outcome studies as the basis for a cost-effectiveness comparison of drugs and psychotherapy in the treatment of unipolar depression. The analysis shows that over a 2-year period, fluoxetine alone may result in 33% higher expected costs than individual CBT treatment and the combination treatment may result in 23% higher costs than CBT alone. Supplemental analysis shows that group CBT may only result in a 2% ($596) cost savings as compared to individual treatment. This paper is based in part on a paper presented at the 1996 American Association of Applied and Preventive Psychology National Conference on Prescription Privileges for Psychologists, Reno, Nevada. Address correspondence to David O. Antonuccio, VA Medical Center (116B2), 1000 Locust St., Reno, NV 89520. 187 00o5-7894/97/0187-021051.00/0 Copyright 1997by Associationfor Advancementof BehaviorTherapy All rightsof reproduction in any form reserved.
A N T O N U C C I O ET AL.
The point prevalence of unipolar depression is estimated to be between 3% and 13%, with 20% to 50% of the adult population having a prior history, and as much as 20% experiencing at least some depressive symptoms at any given time (Amenson & Lewinsohn, 1981; Kessler et al., 1994; Oliver & Simmons, 1985). Women are consistently found to have rates of depression twice as high as men. In 1990, at least I1 million Americans experienced an episode of depression, costing the U.S. economy an estimated $44 billion in increased accident rates, increased substance abuse, increased medical hospitalization, and increased somatic illnesses and outpatient medical utilization (Greenberg, Stiglin, Finkelstein, & Berndt, 1993). Antidepressant drug treatment (Morris & Beck, 1974) and cognitive behavior therapy (CBT; Antonuccio, Ward, & Tearnan, 1989) are empirically based treatments for depression that have established clinical efficacy (Antonuccio, Danton, & DeNelsky, 1995). In the era of managed care and limited resources, depression treatments must demonstrate their cost-effectiveness as well as their clinical effectiveness. The current paper addresses the relative clinical effectiveness and cost-effectiveness of drugs and CBT in the treatment of unipolar depression. The comparative outcome literature is briefly reviewed. A costeffectiveness model, previously generated from this outcome...