Belmont, MA—Last year, the FDA approved esketamine, a nasal spray, for treatment-resistant major depressive disorder. Now, a new study suggests the product might be too expensive for widespread use.

The report in Psychiatric Services discussed results of the comparison of the costs and benefits of esketamine. Unlike ketamine, a drug delivered IV to treat severe depression, esketamine is a nasal spray.

Lead author Eric L. Ross, MD, of McLean Hospital in Belmont, MA, reported that “most medications don’t work as well for people with treatment-resistant depression,” adding, “Esketamine has been effective in a population where many other treatments haven’t worked.”

But he cited a problem, explaining, “I want people to use esketamine, but it’s important that it be cost-effective. I don’t want it to put a real strain on our mental health care system.”

The study team used a decision-analytic model parameterized with efficacy data from phase lll randomized trials of esketamine to simulate the effects of treatment with esketamine versus oral antidepressants over a 5-year horizon, from both societal and healthcare sector perspectives.

Designated outcomes included remission and response of depression, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) for esketamine. Researches also calculated value-based prices, defined as the per-dose price at which esketamine would become cost-effective given cost-effectiveness thresholds of $50,000/QALY, $100,000/QALY, and $150,000/QALY. 

The focus was on the efficacy of esketamine versus oral antidepressants (relative risk of 1.39 for remission; 1.32 for response) and the monthly cost of esketamine ($5,572 for month 1; $1,699–$2,244 thereafter).

Results indicate that, over 5 years, esketamine was projected to increase time in remission from 25.3% to 31.1% of life-years, resulting in a gain of 0.07 QALYs. At the same time, esketamine was calculated to increase societal costs by $16,617 and healthcare sector costs by $16,995. 

“Base case ICERs were $237,111/QALY (societal) and $242,496/QALY (healthcare sector). Probabilistic sensitivity analysis showed a greater than 95% likelihood that esketamine’s ICER would be above $150,000/QALY. At a cost-effectiveness threshold of $150,000/QALY, esketamine’s value-based price was approximately $140/dose (versus a current price of $240/dose),” the researchers advise.

Based on that, the authors conclude that esketamine “is unlikely to be cost-effective for management of treatment-resistant depression in the United States unless its price falls by more than 40%.”

“Esketamine is too expensive, but it does work,” Dr. Ross emphasized. “The question now is ‘How do we get the price down?’”

“At the end of the day, it’s not about saving money,” he added. “The goal is to make sure we’re getting the most clinical benefit we can for the money we spend.”
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