This study aimed to estimate the cost-effectiveness of esketamine, a novel intranasally dosed antidepressant, for patients in the United States with treatment-resistant depression.

A decision-analytic model parameterized with efficacy data from phase 3 randomized trials of esketamine was used to simulate the effects of treatment with esketamine versus oral antidepressants over a 5-year horizon, from both societal and health care sector perspectives. Outcomes included remission and response of depression, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) for esketamine. Value-based prices were calculated, 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.Uncertaintyintheseoutcomeswasassessedwithprobabilisticsensitivityanalyses.Keymodelparametersincludedtheefficacyofesketamineversusoralantidepressants(relativeriskof1.39forremission;1.32forresponse)andthemonthlycostofesketamine( 5,572 for month 1; 1,699– 2,244 thereafter).

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. Esketamine increased societal costs by 16,617andhealthcaresectorcostsby 16,995. Base case ICERs were 237,111/QALY(societal)and 242,496/QALY (health care sector). Probabilistic sensitivity analysis showed a greater than 95% likelihood that esketamine’s ICER would be above 150,000/QALY.Atacost-effectivenessthresholdof 150,000/QALY, esketamine’s value-based price was approximately 140/dose(versusacurrentpriceof 240/dose).

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%.