Fluoxetine and imipramine: are there differences in cost-utility for depression in primary care?

Considering the societal perspective in economic evaluations: a systematic review in the case of depression

BACKGROUND

Depressive disorders are associated with a high burden of disease. However, due to the burden posed by the disease on not only the sufferers, but also on their relatives, there is an ongoing debate about which costs to include and, hence, which perspective should be applied. Therefore, the aim of this paper was to examine whether the change between healthcare payer and societal perspective leads to different conclusions of cost-utility analyses in the case of depression.

METHODS

A systematic literature search was conducted to identify economic evaluations of interventions in depression, launched on Medline and the Cost-Effectiveness Registry of the Tufts University using a ten-year time horizon (2008-2018). In a two-stepped screening process, cost-utility studies were selected by means of specified inclusion and exclusion criteria. Subsequently, relevant findings was extracted and, if not fully stated, calculated by the authors of this work.

RESULTS

Overall, 53 articles with 92 complete economic evaluations, reporting costs from healthcare payer/provider and societal perspective, were identified. More precisely, 22 estimations (24%) changed their results regarding the cost-effectiveness quadrant when the societal perspective was included. Furthermore, 5% of the ICURs resulted in cost-effectiveness regarding the chosen threshold (2% of them became dominant) when societal costs were included. However, another four estimations (4%) showed the opposite result: these interventions were no longer cost-effective after the inclusion of societal costs.

CONCLUSIONS

Summarising the disparities in results and applied methods, the results show that societal costs might alter the conclusions in cost-utility analyses. Hence, the relevance of the perspectives chosen should be taken into account when carrying out an economic evaluation. This systematic review demonstrates that the results of economic evaluations can be affected by different methods available for estimating non-healthcare costs.

Chronic stress exacerbates neuropathic pain via the integration of stress-affect-related information with nociceptive information in the central nucleus of the amygdala

Exacerbation of pain by chronic stress and comorbidity of pain with stress-related psychiatric disorders, including anxiety and depression, represent significant clinical challenges. However, the underlying mechanisms still remain unclear. Here, we investigated whether chronic forced swim stress (CFSS)-induced exacerbation of neuropathic pain is mediated by the integration of stress-affect-related information with nociceptive information in the central nucleus of the amygdala (CeA). We first demonstrated that CFSS indeed produces both depressive-like behaviors and exacerbation of spared nerve injury (SNI)-induced mechanical allodynia in rats. Moreover, we revealed that CFSS induces both sensitization of basolateral amygdala (BLA) neurons and augmentation of long-term potentiation (LTP) at the BLA-CeA synapse and meanwhile, exaggerates both SNI-induced sensitization of CeA neurons and LTP at the parabrachial (PB)-CeA synapse. In addition, we discovered that CFSS elevates SNI-induced functional up-regulation of GluN2B-containing NMDA (GluN2B-NMDA) receptors in the CeA, which is proved to be necessary for CFSS-induced augmentation of LTP at the PB-CeA synapse and exacerbation of pain hypersensitivity in SNI rats. Suppression of CFSS-elicited depressive-like behaviors by antidepressants imipramine or ifenprodil inhibits the CFSS-induced exacerbation of neuropathic pain. Collectively, our findings suggest that CFSS potentiates synaptic efficiency of the BLA-CeA pathway, leading to the activation of GluN2B-NMDA receptors and sensitization of CeA neurons, which subsequently facilitate pain-related synaptic plasticity of the PB-CeA pathway, thereby exacerbating SNI-induced neuropathic pain. We conclude that chronic stress exacerbates neuropathic pain via the integration of stress-affect-related information with nociceptive information in the CeA.

Depression and pain: an appraisal of cost effectiveness and cost utility of antidepressants

BACKGROUND

Although depression and chronic pain frequently co-occur, there is a lack of clarity in the literature regarding the cost-effectiveness and cost-utility of antidepressants in the presence of these two conditions. From the perspective of healthcare provider, the current study aims to compare the cost-effectiveness and cost-utility of antidepressants in a national cohort of depressed patients with and without comorbid pain conditions.

METHODS

Adult patients prescribed with antidepressants for depression were identified from the National Health Insurance Research Database in Taiwan (n=96,501). By using remission as effectiveness measure and quality-adjusted life years (QALYs) as utility measure, the cost-effectiveness and cost-utility were compared across selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), as well as by the presence of comorbid painful physical symptoms (PPS).

RESULTS

SSRIs dominated SNRIs in both the cost-effectiveness and cost-utility regardless of comorbid PPS. In comparison with TCAs, SSRIs were likely to be the cost-effective option for patients without PPS. In patients with PPS, the cost-utility advantage for SSRIs over TCAs varied with threshold willingness-to-pay levels. Comorbid PPS may be considered an effect modifier of the cost-utility comparisons between SSRIs and TCAs.

CONCLUSIONS

For depressed patients without PPS, SSRIs are likely to be cost-effective in improving remission rates and QALYs compared to TCAs and SNRIs. However, to improve cost-utility in those with comorbid PPS, people need to choose between SSRIs and TCAs according to threshold willingness-to-pay levels. Future research is warranted to clarify the impacts of different pain conditions on the economic evaluations of pharmacological treatments in patients with depression.

Pharmacological treatment of depression with and without headache disorders: an appraisal of cost effectiveness and cost utility of antidepressants

BACKGROUND

Depression and headache are highly prevalent in clinical settings. The co-occurrence of headache may impact choice of antidepressants, healthcare utilisation, and outcomes in patients with depression. The current study aims to examine the cost-effectiveness and cost-utility of different antidepressants for treating patients with depression and comorbid headache disorders.

METHODS

Adult patients prescribed with antidepressants for depression (n=96,501) were identified from the National Health Insurance Research Database in Taiwan. A cost-effectiveness and cost-utility analysis was conducted comparing selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), and by the presence of comorbid headache disorders and other pain conditions.

RESULTS

In this study, SSRIs dominated SNRIs in both cost-effectiveness and cost-utility. As revealed in the cost-effectiveness acceptability curves, TCAs were likely to have a cost-utility advantage compared to SSRIs and SNRIs in improving quality-adjusted life years (QALYs) for patients with comorbid headache; SSRIs remained as the most cost-effective option for patients with other pain conditions.

LIMITATIONS

Limitations include the use of proxy definition of remission as effectiveness measure and the adoption of utility values from previous studies.

CONCLUSIONS

Given a pre-determined willingness-to-pay level, TCAs can be considered as a cost-effective option to improve QALYs for depressed patients with headache disorders. Future research is needed to further clarify factors influencing the cost-effectiveness and cost-utility of pharmacological treatments in depressed patients with specific pain conditions.

Cost-effectiveness and cost-utility of selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and tricyclic antidepressants in depression with comorbid cardiovascular disease

OBJECTIVE

There is a lack of clarity in the literature regarding the cost-effectiveness and cost-utility of antidepressants for treating real-world patients. The impact of comorbid cardiovascular disease (CVD) on the economic evaluations of antidepressants remains to be determined.

METHOD

Adult patients prescribed with antidepressants for depression were identified from the National Health Insurance Research Database in Taiwan. A cost-effectiveness and cost-utility analysis was conducted comparing selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), and by the presence of comorbid CVD.

RESULTS

In terms of treatment success rates, SSRIs were the most cost-effective option compared to TCAs and SNRIs as revealed in the incremental cost-effectiveness ratios. The cost-effectiveness acceptability curves further showed differential findings in the cost-utility results by the presence of comorbid CVD.

CONCLUSION

To improve treatment success rates and quality-adjusted life years, SSRIs can be considered the most cost-effective option. Future research is needed to further clarify the impacts of physical comorbidities and other associated factors on the cost-effectiveness and cost-utility of pharmacological treatments in patients with depression.

Utility Values for Adults with Unipolar Depression: Systematic Review and Meta-Analysis

BACKGROUND

Unipolar depression is a mental illness with a substantial health-related and economic burden. Health interventions for depression predominately focus on improving sufferers' health-related quality of life (HRQoL). Utility is a measure of HRQoL that is required for use in model-based cost-utility analyses to assess the added value of health interventions. This review aimed to identify, summarize, and where feasible, synthesize published utilities for unipolar depression.

METHODS

A structured electronic search combining common terms for unipolar depression and utility was conducted in MEDLINE, EMBASE, and PsycINFO. Utility values identified were summarized, and the study designs were appraised in terms of the patient population and valuation method used to generate utilities. Random-effect meta-analyses were applied to pool mean utilities identified for 3 depressive health states (mild, moderate, and severe) elicited from direct and indirect valuation methods separately.

RESULTS

Thirty-five studies were identified that reported utilities for various levels of depression severity. The most commonly used direct valuation method for eliciting utilities was standard gamble (SG) (n = 5), and the most commonly used indirect valuation method was EQ-5D (n = 20). The pooled mean (standard deviation) utilities from studies using SG as a direct valuation method were mild = 0.69 (0.14), moderate = 0.52 (0.28), and severe = 0.27 (0.26). The pooled utilities from studies using EQ-5D as an indirect valuation method were mild = 0.56 (0.16), moderate = 0.45 (0.18), and severe = 0.25 (0.15).

CONCLUSIONS

This systematic review is a useful resource for decision analysts who need health-related utility values to populate model-based cost-utility analyses of health interventions for the management of unipolar depression. Further research is necessary to understand whether direct or indirect valuation methods are the most robust sources for utilities in depression.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

Cost-effectiveness comparisons between antidepressant treatments in depression: evidence from database analyses and prospective studies

BACKGROUND

Knowledge regarding the relative cost-effectiveness of different antidepressants is crucial for the planning of depression treatment. However, there have been only a small number of reviews of such evidence and synthesizing economic evidence across studies is methodologically challenging. In particular, there have been few reviews of the methods employed in database analyses (studies that use data from real-world practice).

METHODS

Published economic evaluations based on database analyses were systematically reviewed to compare antidepressant treatments in depression. Prospective studies of cost-effectiveness were also reviewed to highlight unanswered questions through comparisons between these two different study designs.

RESULTS

Forty papers met the criteria and were included. A relatively large number of industry-sponsored evaluations of escitalopram were identified and these found escitalopram to be potentially cost-effective in depression treatment. Evidence of cost-effectiveness differences between other individual SSRIs was not unequivocally established. Inconsistent findings further emerged concerning the cost-effectiveness of SSRIs versus TCAs between retrospective database analyses and prospective studies.

LIMITATIONS

Different outcome measures and cost perspectives make it difficult to make comparisons across studies.

CONCLUSIONS

Evidence regarding the cost-effectiveness of different antidepressants in depression continues to accumulate. Beyond the efficacy or tolerability data found for newer antidepressants in controlled trials, further research from real-world settings is needed to examine the relative cost-effectiveness of different antidepressant agents.