CBT and MBCT compared using a lifetime Markov cost–utility model.

CBT yields modest QALY gains at higher cost, ICER well below $50,000/QALY.

MBCT remains competitive, favored in lower WTP or resource-limited settings.

Secenario analyses confirm results robust across discount rates and horizons.

Findings inform relapse prevention policy in primary care for adults with MDD.

Major depressive disorder (MDD) is a chronic condition with high relapse rates affecting patients and health systems. Cognitive behavioral therapy (CBT) and mindfulness-based cognitive therapy (MBCT) are strategies for relapse prevention, but their comparative long-term cost-effectiveness remains unclear.

We developed a cohort-based Markov model with three health states, depressive episode, remission, and death, to compare MBCT and CBT in adults with MDD. The model used a lifetime horizon, six-month cycles, with healthcare payer and societal perspectives. Costs included direct medical and productivity losses discounted at 1.5%. Health-state utilities were drawn from published sources. Incremental cost-effectiveness ratios (ICERs) and net monetary benefit (NMB) were estimated at willingness-to-pay (WTP) thresholds of $50,000 and $100,000 per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses, plus scenario analyses with alternative horizons and discount rates, assessed uncertainty.

In the base case, MBCT was associated with 14.71 QALYs at a cost of $543,861, while CBT yielded 15.07 QALYs at $549,487. CBT provided an incremental 0.37 QALYs at $5625 higher cost, producing an ICER of $15,266 per QALY gained, well below both thresholds. NMB favored CBT ($204,242 vs. $191,443 at $50,000; $957,971 vs. $926,746 at $100,000). Sensitivity analyses highlighted remission- and depression-related costs as main drivers. Probabilistic analyses showed CBT optimal in 56% of simulations at $50,000 and 61% at $100,000, with MBCT preferred at lower thresholds.

CBT may be more cost-effective relative to MBCT for relapse prevention in MDD, though differences are modest. MBCT remains a competitive alternative where CBT access is limited.

Major depressive disorder

Relapse

Primary care

Markov model

Psychotherapy

CBT

MBCT

© 2026 The Author(s). Published by Elsevier B.V.