Key result
The Step-Dep intervention was not cost-effective compared to usual care and did not significantly reduce the 12-month cumulative incidence of major depression (13.4% vs 11.6%).
Why the study?
Patients with DM2 and/or CHD are at high risk for major depression, and preventing incident major depression may reduce personal and societal burden.
Does a stepped care program prevent major depression and improve QALYs in primary care patients with diabetes mellitus type 2 and/or coronary heart disease and subthreshold depression?
RCT (n=236)
Open-label
Cluster-randomized
Yes
Does a stepped care program prevent major depression and improve QALYs in primary care patients with diabetes mellitus type 2 and/or coronary heart disease and subthreshold depression?
Mean Difference: 0.018 (95% CI -0.077–0.113)
Absolute Event Rate: 13.4% vs 11.6%
A stepped care program for subthreshold depression in primary care patients with diabetes or coronary heart disease was not cost-effective and did not significantly improve QALYs or prevent major depression compared to usual care.
Step-Dep should not be implemented for depression prevention in DM2/CHD; leaves open whether optimized programs could achieve cost-effectiveness.
BACKGROUND: Patients with diabetes mellitus type 2 (DM2) and/or coronary heart disease (CHD) are at high risk to develop major depression. Preventing incident major depression may be an important tool in reducing the personal and societal burden of depression. The aim of the current study was to assess the cost-effectiveness of a stepped care program to prevent major depression (Step-Dep) in diabetes mellitus type 2 and/or coronary heart disease patients with subthreshold depression in comparison with usual care. METHODS: An economic evaluation with 12 months follow-up was conducted alongside a pragmatic cluster-randomized controlled trial from a societal perspective. Participants received care as usual (n = 140) or Step-Dep (n = 96) which consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to a general practitioner. Primary outcomes were quality-adjusted life years (QALYs) and cumulative incidence of major depression. Costs were measured every 3 months. Missing data was imputed using multiple imputation. Uncertainty around cost-effectiveness outcomes was estimated using bootstrapping and presented in cost-effectiveness planes and acceptability curves. RESULTS: There were no significant differences in QALYs or depression incidence between treatment groups. Secondary care costs (mean difference €1644, 95% CI €344; €3370) and informal care costs (mean difference €1930, 95% CI €528; €4089) were significantly higher in the Step-Dep group than in the usual care group. The difference in total societal costs (€1001, 95% CI €-3975; €6409) was not statistically significant. The probability of the Step-Dep intervention being cost-effective was low, with a maximum of 0.41 at a ceiling ratio of €30,000 per QALY gained and 0.32 at a ceiling ratio of €0 per prevented case of major depression. CONCLUSIONS: The Step-Dep intervention is not cost-effective compared to usual care in a population of patients with DM2/CHD and subthreshold depression. Therefore, widespread implementation cannot be recommended. TRIAL REGISTRATION: The trial was registered in the Netherlands Trial Register ( NTR3715 ).
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Dijk et al. (2021) conducted an RCT in Diabetes mellitus type 2 and/or coronary heart disease with subthreshold depression (n=236). Step-Dep (stepped care program) vs. Usual care was evaluated on Cumulative incidence of major depression at 12 months (MD 0.018, 95% CI -0.077 to 0.113). The Step-Dep intervention was not cost-effective compared to usual care and did not significantly reduce the 12-month cumulative incidence of major depression (13.4% vs 11.6%).
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