The cost-utility of screening for depression in primary care

Background: Depressive disorders are common in primary care and cause subst antial disability, but they often remain undiagnosed. Screening is a freque ntly proposed strategy for increasing detection of depression. Objective: To examine the cost-utility of screening for depression compared with no screening. Design: Nonstationary Markov model. Data Sources: The published literature. Time Horizon: Lifetime. Perspective: Health care payer and societal. Interventions: Self-administered questionnaire followed by provider assessm ent. Outcome Measures: costs and quality-adjusted life-years (QALYs). Results of Base-Case Analysis: Compared with no screening, the cost to soci ety of annual screening for depression in primary care patients is $192 444 /QALY. Screening every 5 years and one-time screening cost $50 988/QALY and $32 053/QALY, respectively, compared with no screening. From the payer per spective, the cost of annual screening is $225 467. Results of Sensitivity Analyses: Cost-utility ratios are most sensitive to the prevalence of major depression, the costs of screening, rates of treatm ent initiation, and remission rates with treatment. In Monte Carlo sensitiv ity analyses, the cost-utility of annual screening is less than $50 000/QAL Y only 2.2% of the time. In multiway analyses, four model variables must be changed to extreme values for the cost-utility of annual screening to fall below $50 000/QALY, but a change in only one variable increases the cost-u tility of one-time screening to more than $50 000/QALY. One-time screening is more robustly cost-effective if screening costs are low and effective tr eatments are being given. Conclusions: Annual and periodic screening for depression cost more than $5 0 000/QALY, but one-time screening is cost-effective. The cost-effectivenes s of screening is likely to improve if treatment becomes more effective.