OBJECTIVES: Older adults under treatment with oral antidepressants (ADs) experience an increased risk of falls compared to non-users. Cognitive behavioral therapy (CBT) is an appropriate first-line alternative for the treatment of depression in older adults. There are currently no economic evaluations conducted comparing the two treatments. This research aims to explore the cost-effectiveness of CBT compared with oral ADs for depression in older adults, considering the risk of falls, fall-related emergency room visits (ERV) and their related consequences from a US Medicare perspective.

METHODS: A decision tree was constructed for a hypothetical cohort of community-dwelling older adults diagnosed with depression over one year. Older adults who experience a fall will travel down a cascade of events (e.g., medical attention, ERV, hospitalization, fractures). Probability, cost, and utility inputs were derived from publicly available literature and resources. The main outcome measure was incremental cost per quality-adjusted life year (QALY) gained.

RESULTS: CBT (cost: $1,898; QALYs: 0.62) incurred greater costs and higher QALYs compared to oral ADs (cost: $1,113; QALYs: 0.61), resulting in an incremental cost-effectiveness ratio (ICER) of $115,862 per QALY gained (range: $7,747/QALY to $1,265,835/QALY). The model was most sensitive to the probability value of falls with oral ADs. The ICERs for CBT compared with oral ADs were reduced substantially in the scenarios where patients were only treated with group CBT instead of private CBT (ICER $6,462/QALY) and patients were treated with serotonin norepinephrine reuptake inhibitors instead of selective serotonin reuptake inhibitors (ICER $56,327/QALY).

CONCLUSIONS: CBT is likely moderately cost-effective compared to oral ADs in older adults with depression per willingness-to-pay threshold of $150,000/QALY. Falls associated with oral ADs is notable and deserves consideration in clinical decision-making and future economic evaluations with older adults. A randomized controlled trial of CBT vs. oral ADs in older adults with depression is warranted to capture true efficacy differences.