Cost-effectiveness of systematic depression treatment among people with diabetes mellitus

Context: Depression co-occurring with diabetes mellitus is associated with higher health services costs, suggesting that more effective depression treatment might reduce use of other medical services. Objective: To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among outpatients with diabetes. Design: Randomized controlled trial comparing systematic depression treatment program with care as usual. Setting: Primary care clinics of group-model prepaid health plan. Patients: A 2-stage screening process identified 329 adults with diabetes and current depressive disorder. Intervention: Specialized nurses delivered a 12-month, stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program. Subsequent treatment ( combining psychotherapy and medication, adjustments to medication, and specialty referral) was adjusted according to clinical response. Main Outcome Measures: Depressive symptoms were assessed by blinded telephone assessments at 3, 6, 12, and 24 months. Health service costs were assessed using health plan accounting records. Results: Over 24 months, patients assigned to the intervention accumulated a mean of 61 additional days free of depression ( 95% confidence interval [ CI], 11 to 82 days) and had outpatient health services costs that averaged $314 less ( 95% CI, $1007 less to $379 more) compared with patients continuing in usual care. When an additional day free of depression is valued at $10, the net economic benefit of the intervention is $952 per patient treated ( 95% CI, $244 to $1660). Conclusions: For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.