Adjunctive cognitive therapy is more effective, but more costly, than standard clinical management for replase prevention in depression

Scott J, Palmer S, Paykel E et al. Use of cognitive therapy for relapse prevention in chronic depression. Brit J Psychiatry 2003 Mar;182:221–7

COMMENTARY

Although there is evidence that cognitive behaviour therapy (CBT) can reduce the risk of relapse, the actual costs of preventing such relapse have not been clearly described. This study assesses the cost effectiveness of adding CBT to clinical management and antidepressant medication for relapse prevention. The authors collated the costs of CBT therapists and other health services used. The findings suggest that adjunctive therapy decreases the risk of relapse and promotes more depression-free days. Cognitive therapy is expensive, however, costing £4000–5000 per relapse prevented.

This paper raises a number of intriguing questions about the effectiveness and costs of depression treatment. The first question is whether clinical management is needed if patients receive supervision by the CBT therapist during their CBT training sessions. Clinical management is an important ingredient in the outcome of depression.1 If clinical management could be achieved within CBT sessions, however, the relative cost of CBT may not be much greater than the costs of clinical management plus antidepressant medication. More importantly, alternatives to face to face CBT could be considered. There is increasing evidence that bibliotherapy, computer assisted CBT and internet assisted CBT effectively reduce symptoms of depression.2,3 Internet-based interventions are portable, accessible and personalised, and reminders can be automated. Although there are some caveats,4 developing an internet-based relapse prevention package may be a good investment.