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Cost-Effectiveness of Prolonged Exposure Therapy Versus Pharmacotherapy and Treatment Choice in Posttraumatic Stress Disorder (the Optimizing PTSD Treatment Trial): A Doubly Randomized Preference Trial

J Clin Psychiatry 2014;75(3):222-230
10.4088/JCP.13m08719

Objective: Cost-effectiveness of treatment for posttraumatic stress disorder (PTSD) may depend on type of treatment (eg, pharmacotherapy vs psychotherapy) and patient choice of treatment. We examined the cost-effectiveness of treatment with prolonged exposure therapy versus pharmacotherapy with sertraline, overall treatment preference, preference for choosing prolonged exposure therapy, and preference for choosing pharmacotherapy with sertraline from the US societal perspective.

Method: Two hundred patients aged 18 to 65 years with PTSD diagnosis based on DSM-IV criteria enrolled in a doubly randomized preference trial. Patients were randomized to receive their treatment of choice (n = 97) or to be randomly assigned treatment (n = 103). In the choice arm, patients chose either prolonged exposure therapy (n = 61) or pharmacotherapy with sertraline (n = 36). In the no-choice arm, patients were randomized to either prolonged exposure therapy (n = 48) or pharmacotherapy with sertraline (n = 55). The total costs, including direct medical costs, direct nonmedical costs, and indirect costs, were estimated in 2012 US dollars; and total quality-adjusted life-year (QALY) was assessed using the EuroQoL Questionnaire-5 dimensions (EQ-5D) instrument in a 12-month period. This study was conducted from July 2004 to January 2009.

Results: Relative to pharmacotherapy with sertraline, prolonged exposure therapy was less costly (–$262; 95% CI, –$5,068 to $4,946) and produced more QALYs (0.056; 95% CI, 0.014 to 0.100) when treatment was assigned, with 93.2% probability of being cost-effective at $100,000/QALY. Independently, giving a choice of treatment also yielded lower cost (–$1,826; 95% CI, –$4,634 to $749) and more QALYs (0.010; 95% CI, −0.019 to 0.044) over no choice of treatment, with 87.0% probability of cost-effectiveness at $100,000/QALY.

Conclusions: Giving PTSD patients a choice of treatment appears to be cost-effective. When choice is not possible, prolonged exposure therapy may provide a cost-effective option over pharmacotherapy with sertraline.

Trial Registration: ClinicalTrials.gov identifier: NCT00127673

J Clin Psychiatry 2014;75(3):222–230

Submitted: August 6, 2013; accepted December 18, 2013 (doi:10.4088/JCP.13m08719).

Corresponding author: Quang A. Le, PharmD, PhD, Department of Social and Administrative Sciences, Western University of Health Sciences, 309 E. Second St, Pomona, CA 91766-1854 (qle@westernu.edu).