Psychological Medicine

One size fits some: the impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention 1

a1 VA HSRD Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, and the University of Arkansas for Medical Sciences, Department of Psychiatry, Little Rock, AR, USA
a2 Department of Family Medicine, University of Colorado Health Sciences Center, Denver, CO, USA
a3 Center for Research Strategies, Denver, CO, USA
a4 Department of Biometry, University of Arkansas for Medical Sciences, AR, USA
a5 Department of Psychiatry, University of Pennsylvania Health System, PA, USA

Article author query
pyne jm   [PubMed][Google Scholar] 
rost km   [PubMed][Google Scholar] 
farahati f   [PubMed][Google Scholar] 
tripathi sp   [PubMed][Google Scholar] 
smith j   [PubMed][Google Scholar] 
keith williams d   [PubMed][Google Scholar] 
fortney j   [PubMed][Google Scholar] 
coyne jc   [PubMed][Google Scholar] 


Background. Despite their impact on outcomes, the effect of patient treatment attitudes on the cost-effectiveness of health-care interventions is not widely studied. This study estimated the impact of patient receptivity to antidepressant medication on the cost-effectiveness of an evidence-based primary-care depression intervention.

Method. Twelve community primary-care practices were stratified and then randomized to enhanced (intervention) or usual care. Subjects included 211 patients beginning a new treatment episode for major depression. At baseline, 111 (52·6%) and 145 (68·7%) reported receptivity to antidepressant medication and counseling respectively. The intervention trained the primary-care teams to assess, educate, and monitor depressed patients. Twelve-month incremental (enhanced minus usual care) total costs and quality-adjusted life years (QALYs) were calculated.

Results. Among patients receptive to antidepressants, the mean incremental cost-effectiveness ratio was $5864 per QALY (sensitivity analyses up to $14689 per QALY). For patients not receptive to antidepressants, the mean incremental QALY score was negative (for both main and sensitivity analyses), or the intervention was at least no more effective than usual care.

Conclusions. These findings suggest a re-thinking of the ‘one size fits all’ depression intervention, given that half of depressed primary-care patients may be non-receptive to antidepressant medication treatment. A brief assessment of treatment receptivity should occur early in the treatment process to identify patients most likely to benefit from primary-care quality improvement efforts for depression treatment. Patient treatment preferences are also important for the development, design, and analysis of depression interventions.

c1 Dr Jeffrey M. Pyne, Central Arkansas Veterans Healthcare System, Center for Mental Healthcare Outcomes Research, 2200 Fort Roots Drive, Building 58 (152/NLR), North Little Rock, AR 72114-1706, USA. (Email:


1 Earlier versions of this work were presented at the International Health Economics Association Meeting, York, UK, July 2001 and the Fifth Workshop on Costs and Assessment in Psychiatry sponsored by the World Psychiatric Association Section on Mental Health Economics, Chicago, IL, USA, May 2000.