Is universal depression screening cost-effective across all Indian states? Addressing parameter uncertainty

We read with great interest the article by Purohit et al. evaluating the cost-effectiveness of universal depression screening in India's primary healthcare system. 1 The study addresses a critical evidence gap for mental health policy in low-and middle-income countries.However, there are some limitations to cons.First, the representativeness of utility values merits attention.The EQ-5D-5L utility scores were derived from 259 patients attending the psychiatry outpatient department of a tertiary care hospital.This sampling approach risks selection bias, as patients attending a tertiary hospital psychiatry likely represent more severe cases or individuals with greater treatment-seeking propensity compared to those identified through community-based screening.2 Patients detected via population screening often include asymptomatic or mildly symptomatic individuals who may report higher baseline utility values.Consequently, the incremental utility gain attributable to screening and treatment could be overestimated.Given that quality-adjusted life years (QALYs) constitute the primary outcome measure in cost-utility analysis, even modest deviations in utility parameters could substantially alter the incremental cost-utility ratios (ICURs).We suggest that future validation studies measure utilities directly in communityscreened populations, or that broader sensitivity analyses be conducted around these parameters.Second, the treatment adherence assumptions appear optimistic.The model incorporates a 10% lossto-follow-up rate during the treatment phase, implying approximately 90% treatment retention rate.However, published evidence consistently demonstrates that real-world adherence to antidepressant therapy is considerably lower.A systematic review found that six-month non-adherence rates averaged 46-52% across psychiatric and primary care populations.3 More recent real-world data from population-based cohorts report overall adherence rates as low as 31% over 12 months.3 These challenges may be more pronounced in resource-limited settings where transportation difficulties, medication-related stigma, and limited follow-up infrastructure are prevalent.The treatment efficacy parameters employed in