OBJECTIVES

Treatment-resistant depression (TRD) is defined as failure to achieve adequate response to ≥2 antidepressant (AD) treatment trials of adequate dosage and duration. Esketamine nasal spray was granted breakthrough designation for TRD by the Food and Drug Administration and, if approved, would be the first glutamate receptor modulator for depression. Phase 3 clinical trials of esketamine in TRD showed efficacy across 4-week and maintenance studies; adverse events (AE) were generally mild to moderate and resolved the same day. However, economic outcomes with esketamine treatment are unknown. This analysis assessed the cost-effectiveness of esketamine+oral AD versus oral AD alone from a societal and US payer’s perspective.

METHODS

A Markov cohort economic model was developed. The model follows patients through known health states of TRD (major depressive episode, response, remission, and recovery), considering the occurrence of relapse and recurrence, and translates the time spent in each health states into quality-adjusted life-years (QALY) and costs. Transition probabilities, relapse rates, and utility scores were from esketamine trials. Long-term data from the literature were used to supplement trials’ data. Costs (in 2018 US Dollars) of drug acquisition, disease and AEs management, and productivity were from public databases and the literature. Clinical and economic outcomes were projected over 5 years and discounted at 3.0% per year.

RESULTS

Over 5 years, esketamine+oral AD yielded greater clinical benefits that translated into higher QALYs and savings in disease management costs compared with oral ADs alone. The total costs were higher with esketamine+oral ADs when factoring in drug acquisition costs. However, the resulting incremental cost per QALY gain was below a willingness-to-pay threshold of $100,000 per QALY gained. Deterministic and probabilistic sensitivity analyses confirmed that the results were robust.

CONCLUSIONS

Esketamine+oral ADs is a cost-effective treatment alternative for patients with TRD in the US.