Cost-effectiveness of group psychotherapy for depression in Uganda.

BACKGROUND: Low and middle-income countries are increasingly acknowledging the potential health and economic benefits associated with treatment of depression. To aid countries in making resource-allocation decisions, there is a need for cost-effectiveness analysis of treatments for depression in developing countries. Although there are a limited number of studies from developing countries that report data on treatment efficacy and costs, these data can be leveraged to tailor mathematical models that are used to evaluate the cost-effectiveness of depression treatments in specific settings. AIMS OF THE STUDY: Using data from depression studies in the published literature, as well as two studies in Uganda, we developed a decision-analytic model to evaluate the cost-effectiveness of group psychotherapy in the setting of Uganda.
METHODS: We developed a Markov cohort model of depression and evaluated the health benefits and costs associated with group psychotherapy with and without booster sessions for recurrent depressive episodes. We synthesized published data on the epidemiology of depression, treatment efficacy, and costs to parameterize our model, and used data from developing countries where available. Outcomes included quality-adjusted life expectancy (QALY), lifetime costs, and incremental cost-effectiveness ratios (ICER). Costs were expressed in international dollars (I$) to facilitate comparisons across settings and studies.
RESULTS: In Uganda, group psychotherapy without booster sessions decreased average number of depressive episodes by 6.2%, compared to no intervention; with booster sessions, reduction in number of episodes increased to 15.8%. Although group psychotherapy alone was less costly than psychotherapy with booster sessions, the ICER was higher, and therefore, group psychotherapy without booster sessions was dominated. The ICER associated with psychotherapy with booster sessions was I$ 1,150 per QALY, compared to no intervention. Although higher than previously published cost-effectiveness estimates of treatments for depression, HIV and cardiovascular disease in the developing world, the ICER of psychotherapy with booster sessions falls below Uganda's per-capita GDP, a suggested threshold for cost-effectiveness. The results were most sensitive to cost of the booster sessions and health state utility for depression. DISCUSSION: Our results suggest that group psychotherapy treatment with booster sessions for recurrent depressive episodes may be cost-effective in developing countries such as Uganda. These findings can assist in a global campaign for developing countries to provide and upscale appropriate depression treatment programs. However, there are only a limited number of studies on treatments for depression in the developing world with small numbers of enrolled subjects; most inputs to our Markov model relied on data from developed countries. Cultural, political, economic, and social differences between countries may limit the generalizability of our findings. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This study suggests a promising role for group psychotherapy in treating depression. Integration of this service into primary care may result in cost-effective treatment for depression. IMPLICATIONS FOR HEALTH POLICIES: In developing countries with limited health care budgets, group psychotherapy can be a cost-effective treatment option for patients with depression. IMPLICATIONS FOR FURTHER RESEARCH: There are a limited number of clinical studies evaluating efficacy and costs of treatments for depression in developing countries. Research on depression in such settings can further assist in providing accurate and country-contextualized estimates of cost-effectiveness.