OBJECTIVES : To compare the annual per-patient direct and indirect costs associated with achieving remission with esketamine nasal spray plus oral antidepressants (ESK+OAD) versus oral antidepressant plus placebo (OAD+PBO) among patients with treatment-resistant depression (TRD) and determine the break-even net price per ESK device.

METHODS : An Excel-based model was developed to estimate the net prices per ESK device for which the cost-per-remitter for ESK+OAD was the same as OAD+PBO. Separate analyses were conducted from the perspectives of employer-sponsored insurance plans, Medicaid, Veterans Affairs (VA), and Integrated Data Networks (IDN). Remission rates, response rates, and relapse rates (among patients initially remitting or responding) were estimated in 4-week intervals using data from the Phase 3 clinical trials comparing ESK+OAD versus OAD+PBO. Patients not remitting/responding during the first month or experiencing a relapse subsequent to initial remission/response were considered non-responders for the remaining duration. Direct (medical and prescription drug) and indirect costs (lost productivity) associated with each health state were derived from the literature.

RESULTS : Under the base-case scenario, the cumulative relapse-free remission rate at the end of 52 weeks was 38% for ESK+OAD and 17% for OAD+PBO. The break-even net prices per remitted patient over 1 year considering direct costs only were as follows: 1) employer-sponsored plans: $325; 2) Medicaid: $347; 3) VA: $362; and 4) IDN: $470. When including indirect costs, the break-even prices were approximately 200% − 244% higher than those estimated with direct costs alone, depending on the plan type.

CONCLUSIONS : These findings suggest that esketamine nasal spray in conjunction with oral antidepressants is a cost-efficient alternative compared with antidepressant alone for TRD below the net price per device of $325 − $470, depending on the plan type. The benefits associated with ESK+OAD treatment are particularly pronounced when considering the costs associated with lost productivity.