ArticlePLoS medicine2026
Cost-effectiveness of esketamine versus alternative treatment strategies for treatment-resistant depression in Hong Kong: A multi-armed modeling study.
Article in PLoS medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Who cites it
1 citing paper in PubMed.
- Treatment-resistant Depression in the Post-ketamine Era: Unmet Needs beyond Rapid Response.Clinical psychopharmacology and neuroscience : the official scientific journal of the Korean College of Neuropsychopharmacology · 2026Review
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Authors and funding
10 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundTreatment-resistant depression (TRD), defined as failure to respond to at least two adequately administered antidepressant (AD) regimens, imposes major clinical and economic burdens. Esketamine nasal spray offers rapid antidepressant clinical effects, yet previous evaluations compared it only with unrealistic comparators such as AD monotherapy. This study assessed the cost-effectiveness of esketamine versus multiple alternative third-line strategies for TRD from the Hong Kong healthcare payer's perspective. METHODS AND
findingsA Markov cohort model simulated adults with TRD in Hong Kong over 5 years with 4-week cycles. The model compared esketamine plus AD with six alternative third-line treatment strategies: combination therapy (AD plus AD), augmentation therapy (AD plus antipsychotic or lithium), psychotherapy alone, psychotherapy plus AD, repetitive transcranial magnetic stimulation (rTMS) plus AD, and electroconvulsive therapy (ECT) plus AD. Primary outcomes were quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) under a US$50,000/QALY willingness-to-pay (WTP) threshold. Deterministic and probabilistic sensitivity analyses and scenario analyses were conducted, focusing on alternative esketamine dosing, delivery strategies, and comparisons with other treatment options to assess the robustness of the results. In base-case analysis, esketamine was not cost-effective versus augmentation, combination, psychotherapy, or psychotherapy plus AD with ICERs ranging from US$134,127 to US$312,750 per QALY but was more cost-effective than rTMS (dominated) and ECT (ICER: US$322,407/QALY). Combination therapy was the most cost-effective among all strategies evaluated. The main limitation of this study is the reliance on indirect comparisons and assumptions derived from heterogeneous clinical trial populations, which may not fully reflect real-world patient characteristics and treatment pathways.
conclusionsEsketamine appeared more cost-effective than rTMS and ECT, but not cost-effective compared with other commonly used third-line treatment strategies for TRD. These findings suggest that cost-effectiveness evidence may help inform more context-sensitive treatment sequencing strategies beyond conventional line-of-therapy frameworks. Policy approaches such as price negotiation, optimized service delivery, and alternative dosing strategies may improve the value of esketamine for TRD management.
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