Cost-Effectiveness of Universal Routine Depression Screening for Adolescents in Primary Care.

Abstract

Importance: Approximately one-fifth of adolescents in the US experience a major depressive episode each year. Universal depression screening for adolescents is recommended as part of routine pediatric primary care, but its cost-effectiveness is unclear.

Objective: To evaluate the cost-effectiveness of universal routine depression screening in adolescent primary care compared with usual care.

Design, setting, and participants: This economic evaluation used a decision-analytic model with an embedded state-transition submodel and annual transitions. A hypothetical population of 1000 adolescents and young adults from ages 12 to 22 years, including 12 demographic groups of disaggregated combinations of sex (female and male) and race or ethnicity (American Indian or Alaska Native; Asian, Native Hawaiian, or Pacific Islander; Black or African American; Hispanic, Latino, or Spanish; White; and multiracial or other race or ethnicity) was simulated in pediatric primary care settings.

Exposures: Universal depression screening of varying frequencies, including annual, biennial, and single-time screening at age 12 years, compared with usual care, defined as 20% annual screening rate.

Main outcomes and measures: Costs, health effects as measured by quality-adjusted life-years (QALYs) and depression-free days, and incremental cost-effectiveness ratios (ICERs) from the health care sector and limited societal perspectives.

Results: A universal annual screening policy had an ICER of $66 822 per QALY or $84 per depression-free day gained compared with single-time screening from the limited societal perspective, including caregiver time costs. Universal single-time screening had an ICER of $44 483 per QALY and $62 per depression-free day gained compared with usual care. Targeted universal depression screening was more cost-effective for female individuals and those who identified as Hispanic, Latina, or Spanish, multiracial, or other race or ethnicity. Results were sensitive to treatment recovery rates, depression health state utility scores, treatment costs involving psychotherapy, suicide-related hospitalization costs, and initial depression prevalence at age 12 years. In approximately 99.8% of probabilistic simulations, universal annual screening had an ICER less than $150 000 per QALY threshold.

Conclusions and relevance: The study results suggest that universal annual depression screening for adolescents in primary care is cost-effective compared with a $100 000 per QALY willingness-to-pay threshold. Universal annual screening may be more cost-effective if health systems invest in efforts to enhance family access to telemedicine behavioral health, decrease treatment costs, or improve treatment effectiveness. Future analyses could examine whether additional potentially associated demographic factors, such as gender orientation, sexual identity, rurality, or comorbidities, affect cost-effectiveness outcomes.