Comparing cost-effectiveness of aripiprazole augmentation with other "next-step" depression treatment strategies: A randomized clinical trial

Abstract

Objective: To compare the cost-effectiveness of 3 common alternate treatments for depression. Methods: The cost-effectiveness analysis was conducted as part of a randomized clinical trial, the Veterans Affairs Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D) trial, in which patients were randomized from December 2012 to May 2015 and followed for 12 weeks in 35 Veterans Affairs medical centers. Depression diagnosis was based on ICD-9 codes. Patients were randomized to standard antidepressant therapy augmented with aripiprazole, standard antidepressant therapy augmented with bupropion, or switch to bupropion. Remission was measured using the 16-item Quick Inventory of Depressive Symptomatology-Clinican Rated. Outcomes included the incremental cost-effectiveness ratio (ICER) comparing costs per remission and costs per qualityadjusted life-year (QALY) with 12 weeks as the time horizon using the health care sector perspective. Results: The mean age of participants enrolled in the trial (N = 1, 522) was 54 years, and participants were predominantly male. The rate of remission at 12 weeks was highest for the aripiprazole augmentation arm (29%), followed by bupropion augmentation (27%), and lowest for switching to bupropion (22%). Switching to bupropion was strongly dominated by bupropion augmentation at an ICER of-$640/remission (95% CI,-$5, 770 to $3, 008). The ICER for the aripiprazole augmentation versus switching to bupropion was $1, 074/remission (95% CI, $47 to $5, 022), and the ICER for aripiprazole augmentation versus bupropion augmentation was $5, 094/remission (95% CI,-$34, 027 to $32, 774). There were no significant differences in QALYs, mental health care costs, employment, or other work and social adjustment outcomes between treatment groups. Conclusions: In treatment of depression with less than optimal response, augmentation with either aripiprazole or bupropion was cost-effective relative to switching to bupropion. Trial Registration: ClinicalTrials.gov identifier: NCT01421342