A comparison of the cost-effectiveness of sertraline versus tricyclic antidepressants in primary care

Costs and Outcomes of Use of Amitriptyline, Citalopram and Fluoxetine in Major Depression: Exploratory Study

Background: The increasing cost of pharmaceuticals in the Czech Republic has led to the restriction on prescriptions of expensive new antidepressants. The aim of the study was to compare the costs and outcomes of using amitriptyline, citalopram and fluoxetine in the treatment of major depression. Methods: Ninety patients (69 women) with a mean age of 44.5 years (S.D.=14.3) suffering from major depression were treated with amitriptyline (N=31), citalopram (N=29) and fluoxetine (N=30). Direct medical costs and effectiveness (indicated by the number of hospitalization-free days) were assessed in a prospective, open, intent-to-treat study. Results: Neither cost nor effectiveness were significantly different among the treatment groups. Conclusion: Amitriptyline treatment is not less expensive nor more effective than citalopram or fluoxetine therapies. There is no advantage in restricting patients from treatment with SSRIs, which have fewer adverse effects and a decreased risk of a lethal overdosage in comparison with tricyclic antidepressants.

Selective serotonin reuptake inhibitor use in primary care: a 5-year naturalistic study

OBJECTIVE

To investigate prescribing trends of selective serotonin reuptake inhibitors (SSRIs) during the course of the Defeat Depression Campaign (1992 to 1996).

METHODS

This study utilised cross-sectional data on the prescribing of SSRIs for the treatment of depression from a large primary care database for the 5 consecutive years of the Defeat Depression Campaign, producing the largest study of SSRI use to date.

RESULTS

A total of 93 600 prescriptions were issued for fluoxetine, paroxetine and sertraline, in 27 210 treatment episodes. Over the 5-year period, there was a five-fold increase in the number of prescriptions issued, and a four-fold increase in the number of patients treated, reflecting a trend for longer periods of treatment. Patients initiating treatment with fluoxetine were most likely and those initiating treatment with sertraline were least likely to complete 60, 90 and 120 consecutive days of treatment. Differences in dose patterns also emerged and were consistent throughout the study. Fluoxetine-treated patients were most likely to remain on the starting dose of 20mg daily, while large numbers of sertraline-treated patients received doses above the recommended dose of 50mg daily. These differences were not apparent from clinical trials, and this may be an artefact of trial design.

CONCLUSION

Differences in the doses prescribed may explain why sertraline-treated patients are less likely to complete an adequate course of antidepressant therapy. Longitudinal studies are required to evaluate fully the clinical significance of these findings.

Cost-effectiveness of combination therapy versus antidepressant therapy for management of depression in Japan

OBJECTIVE

Major depression is expected to become the second leading contributor to disease burden worldwide by 2020. Only a few studies, however, have compared the cost-effectiveness of a combination of cognitive behavioural therapy and antidepressant therapy versus antidepressant therapy alone. The purpose of the present study was therefore to analyse cost-effectiveness, from the perspective of the health-care system and also from a social perspective, comparing combined cognitive behavioural therapy + antidepressant therapy and antidepressant therapy alone in the Japanese setting.

METHOD

A formal decision analytical model was constructed. The analyses were performed from both the perspective of the health-care system and the societal perspective. The clinical outcomes were determined from published articles and reports of expert panels. Because no patient-level data were available, deterministic costing of the different treatment strategies was carried out. Cost-effectiveness was assessed first by determining the incremental cost-effectiveness ratio (ICER) per successfully treated patient, and then by the ICER per quality-adjusted life years (QALYs).

RESULTS

The combined therapy increased the rate of successfully treated patients, QALY of severe depression and QALY of moderate depression by 0.15, 0.08 and 0.04, respectively. The combined therapy proved to be more expensive from the health-care system perspective, but the incremental costs were completely offset by the considerable reduction of productivity loss from the social perspective. From the health-care perspective, the ICER per successfully treated patient, ICER per QALY of severe depression and ICER per QALY of moderate depression were JPY 140,418, JPY 268,550 and JPY 537,100, respectively. All the ICERs appeared to be negative from the social perspective.

CONCLUSION

The combined therapy appeared to be cost-effective from the health-care system perspective and the dominant strategy from the social perspective.

Electroconvulsive therapy and its different indications

In spite of recent developments in the pharmacotherapy of depressive disorders, the delay until clinical improvement can be achieved, and the considerable rate of nonresponse and nonremission, are major problems which remain unresolved. Electroconvulsive therapy (ECT) is a nonpharmacologic biological treatment which has been proven to be a highly effective treatment option, predominantly for depression, but also for schizophrenia and other indications. Though there is a lack of controlled investigations on long-term treatments, ECT can also be used for relapse prevention during maintenance therapies. The safety and tolerability of electroconvulsive treatment have been enhanced by the use of modified stimulation techniques and by progress in modern anesthesia. Thus, today a safe treatment can also be offered to patients with higher somatic risks. ECT still represents an important option, especially in the therapy of treatment-resistant psychiatric disorders after medication treatment failures. Earlier consideration of ECT may reduce the rate of chronic and difficult-to-treat psychiatric disorders.

Composição dos gastos privados com medicamentos utilizados por aposentados e pensionistas com idade igual ou superior a 60 anos em Belo Horizonte, Minas Gerais, Brasil

O objetivo do presente estudo foi analisar a composição dos gastos privados com medicamentos utilizados por indivíduos com 60 anos ou mais de idade, em Belo Horizonte, Minas Gerais, Brasil. A população estudada foi uma amostra representativa de aposentados e pensionistas do Instituto Nacional do Seguro Social (INSS) nessa faixa etária e residentes no Município de Belo Horizonte, entrevistados em um inquérito domiciliar. Foram calculados os gastos mensais com medicamentos obtidos no setor privado e analisada a sua composição considerando as características dos medicamentos. Responderam ao inquérito 667 indivíduos. Foi observado um gasto mensal privado médio de R$ 122,97 (US$ 38,91) com os medicamentos utilizados pelos participantes. Os grupos terapêuticos que representaram uma maior proporção dos gastos totais foram: sistema cardiovascular (26%), sistema nervoso (24%) e trato alimentar e metabolismo (15%). Em relação à categoria de registro dos medicamentos utilizados, os medicamentos de referência foram responsáveis por uma maior proporção dos gastos totais (54%). Os resultados deste estudo podem subsidiar políticas destinadas a melhorar o acesso a medicamentos e às condições sanitárias da população idosa brasileira.

Cost-effectiveness and cost-utility of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine: randomised controlled trial

BACKGROUND

The cost-effectiveness of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) has not been compared in a prospective study in primary care.

AIMS

To determine the relative cost-effectiveness of TCAs, SSRIs and lofepramine in UK primary care.

METHOD

An open-label, three-arm randomised trial with a preference arm. Practitioners referred 327 patients with incident depression.

RESULTS

No significant differences were found in effectiveness or cost-effectiveness. The numbers of depression-free weeks over 12 months (on the Hospital Anxiety and Depression Scale) were 25.3 (95% CI 21.3-29.0) for TCAs, 28.3 (95% CI 24.3-32.2) for SSRIs and 24.6 (95% CI 20.6-28.9) for lofepramine. Mean health service costs per patient were pound 762 (95% CI 553-1059) for TCAs, pound 875 (95% CI 675-1355) for SSRIs and pound 867 (95% CI 634-1521) for lofepramine. Cost-effectiveness acceptability curves suggested SSRIs were most cost-effective (with a probability of up to 0.6).

CONCLUSIONS

The findings support a policy of recommending SSRIs as first-choice antidepressants in primary care.

Evidence of cost-effective treatments for depression: a systematic review

BACKGROUND

High levels of public spending, rising costs of treatments and scarcity of mental health resources have intensified the need for information on the cost-effectiveness of interventions for depression. There have been few reviews that consider the cost-effectiveness of all treatments for depression together.

METHODS

Systematic review of published economic evaluations of interventions for depression to identify where evidence of cost-effectiveness exists and where ambiguity remains.

RESULTS

Fifty-eight papers met the criteria and were included in the review. The quality of the evaluations varied greatly. Evidence establishing the cost-effectiveness of interventions for depression is accumulating; selective serotonin reuptake inhibitors (SSRI) and the newer antidepressants venlafaxine, mirtazepine and nefazodone appear cost-effective compared with older drugs. Despite the availability of high quality economic evaluations of psychological therapies compared to usual care, there is limited evidence of their cost-effectiveness particularly when compared directly to pharmacotherapies. Changes to health systems have been found to be cost-effective in some patient groups, but there is no evidence that screening in primary care populations is a cost-effective strategy.

LIMITATIONS

Vastly different interventions, outcome measures and cost perspectives meant a meta-analysis of costs and effects was not considered possible.

CONCLUSIONS

On the basis of available evidence, it is not possible to identify the most cost-effective strategy for alleviating the symptoms of depression, although the SSRIs and newer antidepressants consistently appear more cost-effective than tricyclic antidepressants in many patient groups. Better quality economic evidence is needed.

Pharmacoeconomic evaluation of antidepressants : a critical appraisal of methods

In recent years, there has been much debate regarding the real cost effectiveness of new antidepressants. This review is an attempt to identify key contentious methodological issues that can impact the reliability, validity and quality of the research on this subject. There are inherent complexities between inputs and outcomes related to depression, and the choice of pharmacoeconomic methodology requires a crucial balance between the study design and its ability to capture relevant information. Knowledge of the real efficiency of antidepressants should always be ascertained with reference to the real-world setting. Studies that show a corresponding balance between internal and external validity, coupled with sound methodology and standardised reporting, have the potential to translate pharmacoeconomics research into real-world, time-relevant decision-making.

Quantitative analysis of sponsorship bias in economic studies of antidepressants

BACKGROUND

Concern is widespread about potential sponsorship influence on research, especially in pharmacoeconomic studies. Quantitative analysis of possible bias in such studies is limited.

AIMS

To determine whether there is an association between sponsorship and quantitative outcomes in pharmacoeconomic studies of antidepressants.

METHOD

Using all identifiable articles with original comparative quantitative cost or cost-effectiveness outcomes for antidepressants, we performed contingency table analyses of study sponsorship and design v. study outcome.

RESULTS

Studies sponsored by selective serotonin reuptake inhibitor (SSRI) manufacturers favoured SSRIs over tricyclic antidepressants more than non-industry-sponsored studies. Studies sponsored by manufacturers of newer antidepressants favoured these drugs more than did non-industry-sponsored studies. Among industry-sponsored studies, modelling studies favoured the sponsor's drug more than did administrative studies. Industry-sponsored modelling studies were more favourable to industry than were non-industry-sponsored ones.

CONCLUSIONS

Pharmacoeconomic studies of antidepressants reveal clear associations of study sponsorship with quantitative outcome.

Cost-effectiveness of a primary care depression intervention

OBJECTIVE

To determine the incremental cost-effectiveness of a quality improvement depression intervention (enhanced care) in primary care settings relative to usual care.

DESIGN

Following stratification, we randomized 12 primary care practices to enhanced or usual care conditions and followed patients for 12 months.

SETTING

Primary care practices located in 10 states across the United States.

PATIENTS/PARTICIPANTS

Two hundred eleven patients beginning a new treatment episode for major depression.

INTERVENTIONS

Training the primary care team to assess, educate, and monitor depressed patients during the acute and continuation stages of their depression treatment episode over 1 year.

MEASUREMENTS AND MAIN RESULTS

Cost-effectiveness was measured by calculating incremental (enhanced minus usual care) costs and quality-adjusted life years (QALYs) derived from SF-36 data. The mean incremental cost-effectiveness ratio in the main analysis was US dollars 15463 per QALY. The mean incremental cost-effectiveness ratios for the sensitivity analyses ranged from US dollars 11341 (using geographic block variables to control for pre-intervention service utilization) to US dollars 19976 (increasing the cost estimates by 50%) per QALY.

CONCLUSIONS

This quality improvement depression intervention was cost-effective relative to usual care compared to cost-effectiveness ratios for common primary care interventions and commonly cited cost-effectiveness ratio thresholds for intervention implementation.

Economic evaluation of antidepressive agents: a systematic critique of experimental and observational studies

The purpose of this study was to examine whether experimental and observational pharmacoeconomic analyses of antidepressant drugs support the choice of one of the selective serotonin reuptake inhibitors or newer antidepressants as first-line treatment for patients with major depression. We systematically reviewed economic evaluations of two or more antidepressants completed in clinical practice. A systematic electronic search yielded 38 studies meeting the inclusion criteria, of which 23 were administrative database analyses, 12 were observational studies, and 3 were randomized clinical trials. Experimental data indicated that tricyclic antidepressants are equivalent to selective serotonin reuptake inhibitors in terms of total expenditure. While the database analyses are susceptible to bias and confounding variables, they provided an added dimension based on observations from everyday clinical practice. The majority of these studies failed to show any significant difference. Taken together, available pharmacoeconomic studies indicate that tricyclic drugs and selective serotonin reuptake inhibitors have similar cost effectiveness in the health care systems where these comparisons have been made.

Antidepressant selection and economic outcome: a review of methods and studies from clinical practice

BACKGROUND

Economic considerations increasingly play a role in the selection of antidepressant drugs and are often based on analyses from prospective and retrospective studies. However, the non-randomisation found in retrospective studies may result in significant selection bias.

AIMS

To highlight the use of statistical methods in non-randomised studies and the application of those methods to economic analyses.

METHOD

The literature on the observational studies of economic outcomes with alternative antidepressants is reviewed and several statistical methodologies to control for biases that can occur in non-randomised study designs are described.

RESULTS

In comparisons of antidepressant drugs, differences in acquisition costs are consistently found to be at least offset by other components of care when broad measures of health care resource utilisation are considered.

CONCLUSIONS

Economic evaluations of antidepressants should be based on broad measures of health care expenditure and can rely on data generated in real-world settings if appropriate statistical methods are used to control for the potential biases of non-randomisation.

Pharmacoeconomic studies of antidepressants: focus on venlafaxine

Newer antidepressants are more expensive in terms of acquisition costs than older drugs. However, cost effectiveness simulations and retrospective analyses of administrative databases of newer antidepressants, including venlafaxine, suggest that the higher acquisition costs may be offset or more than offset by savings of other treatment costs. Because simulations and retrospective studies are vulnerable to multiple methodologic uncertainties, large scale randomized "real-world" cost effectiveness experiments are needed. If venlafaxine in actual practice is more effective or has a more rapid onset of action than SSRIs as suggested by efficacy studies and existing meta-analyses, these effects could translate into pharmacoeconomic advantages.

Long-term costs of treatment for depression: impact of drug selection and guideline adherence

OBJECTIVES

This paper examines three processes: SSRI antidepressant choice, adherence to treatment guidelines, and long-term health care expenditures associated with antidepressant treatment for patients with a diagnosis of depression.

METHODS

Patient records were abstracted from a medical claims database covering employer-provided health care plans. Treatment episodes required a 6-month antidepressant-free prior period; initial treatment with sertraline, paroxetine or fluoxetine; and data on direct medical costs over the 24 months following the initial prescription. The multivariate model of drug selection, patient adherence to antidepressant use guidelines, and cost was subjected to specification testing to rule out the possibility that nonrandom initial antidepressant selection might lead to sample selection bias. Further tests indicated that the results were free of bias due to a possible correlation between antidepressant selection and use of the medication, or because of the endogeneity of use patterns in the process driving cost. However, there was evidence of unobserved variables correlated with both achieving guideline adherent use and expenditures, which might have led to sample selection bias.

RESULTS

Subjects who met the study criteria included 796 initiating therapy with sertraline, 352 with paroxetine, and 882 with fluoxetine. Fluoxetine patients were significantly more likely than sertraline or paroxetine patients to achieve a use pattern that was consistent with guidelines for treating depressive disorder (p < .05). There were no statistically significant differences between the three treatment cohorts in total direct health care expenditures over the 2-year period (p < .05), and depression-related expenditures, other mental health expenditures, and non-mental health care expenditures did not show significant differences across the treatments (p < .05). Natural logged values of antidepressant drug expenditures were predicted to be highest for fluoxetine, followed by sertraline, then paroxetine (p < .01). Predicted log values of mental health expenditures were lower for sertraline relative to fluoxetine.

CONCLUSIONS

Fluoxetine patients had the highest likelihood of using antidepressant medication according to treatment guidelines that were developed to assure quality care. This benefit was achieved without incurring greater total health care expenditures.

Patterns of Disease-Modifying Antirheumatic Drug Use, Medical Resource Consumption, and Cost Among Rheumatoid Arthritis Patients

We compared medical resource use and costs among rheumatoid arthritis (RA) patients receiving alternative disease-modifying antirheumatic drugs (DMARDs). The cohort study used data from a managed care organization. Health plan members who were prescribed DMARD therapy for at least 2 consecutive months, were age 18 years or older, had at least 6 months of DMARD-free enrollment prior to the first DMARD, and had a diagnosis of RA before or during the first month of DMARD were eligible. Median duration of initial DMARD therapy was 10 months overall: 11 months for hydroxychloroquine (n = 252), 15 months for methotrexate (n = 185), 5 months for sulfasalazine (n = 49), and 5 months for other mono/combination therapy (n = 85) (p < 0.0001). The average monthly cost of care was $853, of which $294 (34%) was for RA-coded medical services. In multivariate analyses, monthly RA-coded costs varied significantly by initial DMARD. RA costs and duration of initial therapy varied significantly by initial DMARD.

Economic outcomes associated with tricyclic antidepressant and selective serotonin reuptake inhibitor treatments for depression

OBJECTIVE

To compare the economic outcomes associated with the tricyclic antidepressants (TCAs) and the selective serotonin reuptake inhibitors (SSRIs) in the treatment of depression.

METHOD

A literature review of pertinent studies was performed. The advantages and disadvantages of clinical trials versus observational studies are described, and the breadth of the economic outcome measure chosen for the conclusions reached is discussed.

RESULTS

The inclusion and exclusion criteria of clinical trials, in combination with their strict provider and patient study protocols, limit their generalizability to naturalistic treatment settings. Retrospective studies of patients can provide valuable information about the experiences and costs incurred by patients in actual treatment. However, confounding factors (both observable and unobservable) limit the amount of confidence that can be placed in inferences about treatment effects. Randomized prospective studies with naturalistic follow-on may help to mitigate some of the concern about treatment confounders which has traditionally been associated with non-randomized observational studies.

CONCLUSION

Retrospective studies and one randomized prospective study of the economic outcomes of TCA versus SSRI treatment have found the SSRIs to be less expensive than TCAs when total direct medical expenditures are considered. However, additional studies are needed to address this issue.

Medical resource use and costs among rheumatoid arthritis patients receiving disease-modifying antirheumatic drug therapy

OBJECTIVE

To identify costs among rheumatoid arthritis (RA) patients receiving alternative disease-modifying antirheumatic drug (DMARD) therapies.

METHODS

Using managed care organization data, we identified members who (a) were prescribed any DMARD therapy for two consecutive months between July 1993 and February 1998, (b) were aged > or = 18 years, (c) had > or = 6 months of DMARD-free enrollment prior to the first DMARD, and (d) had a diagnosis of RA.

RESULTS

The average age of the cohort (n = 571) was 51 years, and 70% were women. Mean duration of enrollment following initiation of DMARD therapy (observation period) was 19.5 months; 28.8% of patients switched DMARD regimens. The average monthly cost of care was $853, of which $294 (34%) was for RA-coded medical services. Monthly RA-coded costs varied by DMARD: hydroxychloroquine $227 (n = 252), methotrexate $340 (n = 185); sulfasalazine $233 (n = 49), and other mono/combination therapy $425 (n = 85) (P = 0.001).

CONCLUSION

Costs of RA-coded care in patients receiving DMARDs are low and vary by DMARD.

Comparing SSRI treatment costs for depression using retrospective claims data: the role of nonrandom selection and skewed data

BACKGROUND AND OBJECTIVES

Since conventional randomized clinical trials often do not reflect the real world circumstances of prescribing behavior and patient outcomes, the use of retrospective administrative claims databases (RACD) has become more common in treatment cost comparisons among alternative pharmaceutical compounds. Several recent RACD studies have compared treatment costs for depressed patients prescribed SSRIs such as fluoxetine, sertraline and paroxetine. These cost comparisons have reached mixed conclusions. To begin to explain and reconcile the mixed SSRI cost comparison evidence, we undertake a variety of alternative multivariate analyses using a publicly available RACD.

METHODS AND DATA

The 1995 to 1996 data encompasses a time period when all three SSRIs had become well-established agents. We report and compare results from multivariate linear regressions, logistic regressions, ordered probits and sample selectivity models, and examine robustness when adjustments are made for outlier observations and skewed distributions.

RESULTS AND CONCLUSIONS

While choice of initial SSRI is nonrandom, the effect of sample selectivity on total depression-related and total health care expenditure is neutral across SSRIs. Although most cost measures are numerically greatest for fluoxetine, depression-related outpatient and hospitalization costs do not significantly differ by choice of initial SSRI. These findings are robust to alternative assumptions, specifications, and procedures. Antidepressant medication costs, however, are significantly higher when fluoxetine is the initial SSRI rather than sertraline or paroxetine, reflecting the larger proportion of fluoxetine patients prescribed a daily dosage of two or more capsules. Both total depression-related and total health care log-transformed costs are significantly lower for sertraline than fluoxetine.

Payer costs of patients diagnosed with epilepsy

PURPOSE

To identify the annual cost to a third-party payer of inpatient and outpatient services and prescription drugs for patients diagnosed with epilepsy or convulsions.

METHODS

Retrospective study using administrative and claims data from a private insurer in the Northeast United States with >1.8 million covered lives. Health plan members were included if they had a claim for epilepsy or convulsions and a claim for an antiepileptic drug (AED) between January 1992 and December 1996. Annual costs and frequencies of all medical services, and of services related to epilepsy, were compared among five groups of patients defined by the most intensive procedure they received: invasive therapeutic procedure (group 1); invasive diagnostic procedure without an invasive therapeutic procedure (group 2); noninvasive diagnostic procedure without an invasive procedure (group 3); neurologist or neurosurgeon visit without an invasive procedure or noninvasive diagnostic procedure (group 4); or none of the preceding services (group 5).

RESULTS

In the cohort of 9,090 patients meeting the inclusion criteria, mean age was 38 years, 53% were female, 30% had malignant disease, and 25% had cardiac disease. The mean annual cost of all medical services was $9,617. Mean annual costs of all services were $43,333, $29,847, $11,300, $4,362, and $5,855, and annual costs of inpatient and outpatient encounters coded as epilepsy plus AEDs were $24,369, $10,330, $3,127, $1,079, and $1,086, in groups 1-5, respectively. Services used to stratify patients into the groups accounted for 37% of the total costs.

CONCLUSIONS

The annual costs of medical services for patients with epilepsy are high and vary considerably because of treatment of epilepsy and management of comorbidities.

Antidepressant treatment of juvenile depression

Although depression is increasingly recognized in children and adolescents, these groups have responded to conventional tricyclic antidepressants less robustly than depressed adults. Emerging research suggests that juvenile depression may respond better to serotonergic and atypical pharmacologic agents, so guidelines for selection and administration of these agents are provided.

Economic comparisons of the pharmacotherapy of depression: an overview

As many countries find that their health care expenditure is taking up an increasing proportion of their financial resources, economic aspects of care processes have become more important in the choice of optimal strategies. This review of the economic studies of the comparative treatment of depression shows that nearly every aspect of treatment has important economic consequences. Cost-of-illness studies have documented the high burden on society of this disorder, and the associated loss of productivity and work. Comparative cost-effectiveness/utility studies, the majority of which are based on modelling techniques, have consistently shown a better cost-effectiveness ratio of the newer antidepressants over more traditional tricyclic antidepressants (TCAs), when all therapy-related costs are taken into account.

Tricyclic antidepressant and selective serotonin reuptake inhibitors antidepressant selection and health care costs in the naturalistic setting: a multivariate analysis

BACKGROUND

Providers and payers have an interest in the total health care costs following the initiation of antidepressant treatment in the real world of clinical practice. Analyses of these costs can help evaluate the economic consequences of patient management decisions associated with initial antidepressant selection.

OBJECTIVE

The purpose of this study was to assess the 1-year total direct health care costs for patients initiating therapy with one of the available tricyclic antidepressants (TCAs) or one of the three most often prescribed selective serotonin reuptake inhibitors (SSRIs) - paroxetine, sertraline, or fluoxetine.

METHOD

A two-stage multivariate econometric model and data from fee-for-service private insurance claims between 1990 and 1994 were used to estimate the total direct health care costs following initial antidepressant drug selection for 2693 patients with a 'new' episode of antidepressant treatment. After controlling for both observed and unobserved characteristics, the 1-year total direct health care costs were found to be (1) statistically significantly lower for patients initiating therapy on fluoxetine than for patients initiating therapy on a TCA; (2) statistically significantly lower for patients who initiated therapy on fluoxetine than for patients initiating therapy on sertraline.

CONCLUSIONS

Broadly considered, the findings in this study suggest that total direct health care costs differ across initial antidepressant selection after controlling for both observed and unobserved characteristics.