Cost-effectiveness of esketamine versus alternative treatment strategies for treatment-resistant depression in Hong Kong: A multi-armed modeling study.
PLoS medicine April 1, 2026 Yifan Li, Vivien Kin Yi Chan, Mark Jit et al.
Esketamine nasal spray, a rapid-acting antidepressant for treatment-resistant depression (TRD), was not cost-effective compared with most commonly used third-line strategies in Hong Kong. A Markov model simulated adults with TRD over five years and compared esketamine plus an antidepressant against six alternatives: combination therapy (two antidepressants), augmentation (antipsychotic or lithium), psychotherapy alone, psychotherapy plus antidepressant, repetitive transcranial magnetic stimulation (rTMS) plus antidepressant, and electroconvulsive therapy (ECT) plus antidepressant. Esketamine's incremental cost-effectiveness ratios ranged from US$134,127 to US$312,750 per quality-adjusted life-year (QALY) versus augmentation, combination, psychotherapy, and psychotherapy plus antidepressant—all above a US$50,000/QALY threshold. It was more cost-effective than rTMS (dominated) and ECT (ICER: US$322,407/QALY). Combination therapy was the most cost-effective strategy. Findings rely on indirect comparisons and may not reflect real-world patients.