JMIR Publications

ABSTRACT

Background:

Major depressive disorder (MDD) is one of the leading causes of disability and death by suicide globally. Unguided Internet-based cognitive behavioral therapy (ICBT), with the promise to improve accessibility and affordability, has been proven to be effective for MDD. However, few studies have examined the cost-effectiveness of unguided ICBT for MDD in low-resource countries and under non-specialist routine care.

Objective:

This study aimed to evaluate the short- and long-term cost-utility of unguided ICBT (named Morning Mood, a self-developed course on the WeChat Mini-program) compared to waiting-list control for persons suffering from MDD from the perspectives of society and healthcare system

Methods:

This cost-utility analysis was implemented alongside an 8-week 2-arm pragmatic randomized controlled trial with a 12-month follow-up conducted in Shenzhen City, China (Trial Registration: ChiCTR2100046425). Outcome data including cost and health utility were collected at baseline or pre-treatment, post-treatment, 3, 6, and 12 months after the intervention. Both societal and healthcare system perspectives were adopted. Direct medical costs and indirect costs were prospectively collected through the hospital information system and the Sheehan Disability Scale. Health outcome was measured by the Chinese version of SF-6Dv2. The primary outcome was incremental cost-utility ratio (ICUR), expressed as the difference in costs between two therapies by the difference in quality-adjusted life years (QALYs). Seemingly unrelated regression and the bootstrap method were performed to estimate adjusted ICURs and the corresponding 95% confidence intervals. Cost-effectiveness planes and cost-effectiveness acceptability curves were used to demonstrate the uncertainty of the results. A series of scenario analyses were conducted to verify the robustness of base-case results.

Results:

A total of 244 participants with MDD were randomly allocated to the ICBT (n=122) or the waiting-list (n=122) group. In the base-case analysis, the adjusted ICURs at post-treatment were respectively -194,720.38 and 49,700.33 Chinese Yuan (CNY) per QALY from societal and healthcare system perspectives, with the probability of unguided ICBT being cost-effective of 75.93% and 54.40% if the willingness-to-pay (WTP) was set at 1 time per capita gross domestic product. In scenario analyses, the probabilities respectively increased to 76.85% and 77.61%, indicating the potential of ICBT to be cost-effective over the long term from both the perspectives of society and healthcare system.

Conclusions:

Unguided ICBT is a cost-effective treatment for MDD. This intervention not only helps patients with MDD to improve clinically but also generates societal savings. These findings provide the health economic evidence for a potential scalable MDD treatment method in developing countries. Clinical Trial: Chinese Clinical Trial Registry (ChiCTR2100046425); https://tinyurl.com/bdcrj4zv