When Is It Worth Introducing a Quality Improvement Program? A Mathematical Model

Quality improvement programs must compete with other health care interventions for limited health care resources. The goal of the research presented here was to develop a model that portrays the mathematical relationship between the size of a quality deficit caused by the noncompliance of health professionals and the cost-effectiveness of a quality improvement program. The model allows the determination of the minimum size of a quality deficit for which it is worth introducinga quality improvement program. If a quality improvement program has already been implemented, the model can be used to define the quality threshold beyond which a reduction in quality becomes economically unattractive. An example consideringthe reduction of underuse in depression treatment demonstrates that an intervention with a favorable cost-effectiveness ratio may become economically unattractive once the costs for the implementation effort are considered.

An update on the drug treatment of neuropathic pain. Part 1: antidepressants. Drug Ther Bull. 2012;50:114-117. [PMID: 23065751 DOI: 10.1136/dtb.2012.10.0133]

Neuropathic pain refers to pain that arises as a direct consequence of a lesion or disease affecting the somatosensory nervous system.(1) Many cases of neuropathic pain run a chronic course, and treatment may be difficult because commonly used analgesics, including NSAIDs and to some extent opioids, are often ineffective. In addition, the use of other pharmacological treatments can be limited by unwanted effects. Management requires a multidisciplinary approach and may involve the use of drug therapy (including antidepressants, anticonvulsants and opioids) with non-pharmacological interventions (including psychological therapies, transcutaneous electrical nerve stimulation and interventional procedures). This month and next month we review the drug treatment of neuropathic pain. In this first part we discuss neuropathic pain and the use of antidepressants.

Cost-effectiveness analysis of pharmacologic treatment of fibromyalgia in Mexico

OBJECTIVE

To identify, from the Mexican Public Health System perspective, which would be the most cost-effective treatment for patients with Fibromyalgia (FM).

MATERIAL AND METHODS

A Markov model including three health states, divided by pain intensity (absence or presence of mild, moderate or severe pain) and considering three-month cycles; costs and effectiveness were estimated for amitriptyline (50mg/day), fluoxetine (80 mg/day), duloxetine (120 mg/day), gabapentin (900 mg/day), pregabalin (450 mg/day), tramadol/acetaminophen (150 mg/1300 mg/día) and amitriptyline/fluoxetine (50mg/80 mg/día) for the treatment of FM. The clinical outcome considered was the annual rate of pain control. Probabilities assigned to the model were collected from published literature. Direct medical costs for FM treatment were retrieved from the 2006 data of the Mexican Institute of Social Security (IMSS) databases and were expressed in 2010 Mexican Pesos. Probabilistic Sensitivity Analyses were conducted.

RESULTS

The best pain control rate was obtained with pregabalin (44.8%), followed by gabapentin (38.1%) and duloxetine (34.2%). The lowest treatment costs was for amitriptyline ($ 9047.01), followed by fluoxetine ($ 10,183.89) and amitriptyline/fluoxetine ($ 10,866.01). By comparing pregabalin vs amitriptyline, additional annual cost per patient for pain control would be around $ 50.000 and $ 75.000 and would result cost-effective in 70% and 80% of all cases.

CONCLUSIONS

Among all treatment options for FM, pregabalin achieved the highest pain control and was cost-effective in 80% of patients of the Mexican Public Health System.

Cost-effectiveness analysis of a new 8% capsaicin patch compared to existing therapies for postherpetic neuralgia

OBJECTIVE

The purpose of this study was to compare the cost effectiveness of a new 8% capsaicin patch, compared to the current treatments for postherpetic neuralgia (PHN), including tricyclic antidepressants (TCAs), topical lidocaine patches, duloxetine, gabapentin, and pregabalin.

METHODS

A 1-year Markov model was constructed for PHN with monthly cycles, including dose titration and management of adverse events. The perspective of the analysis was from a payer perspective, managed-care organization. Clinical trials were used to determine the proportion of patients achieving at least a 30% improvement in PHN pain, the efficacy parameter. The outcome was cost per quality-adjusted life-year (QALY); second-order probabilistic sensitivity analyses were conducted.

RESULTS

The effectiveness results indicated that 8% capsaicin patch and topical lidocaine patch were significantly more effective than the oral PHN products. TCAs were least costly and significantly less costly than duloxetine, pregabalin, topical lidocaine patch, 8% capsaicin patch, but not gabapentin. The incremental cost-effectiveness ratio for the 8% capsaicin patch overlapped with the topical lidocaine patch and was within the accepted threshold of cost per QALY gained compared to TCAs, duloxetine, gabapentin, and pregablin. The frequency of the 8% capsaicin patch retreatment assumption significantly impacts its cost-effectiveness results. There are several limitations to this analysis. Since no head-to-head studies were identified, this model used inputs from multiple clinical trials. Also, a last observation carried forward process was assumed to have continued for the duration of the model. Additionally, the trials with duloxetine may have over-predicted its efficacy in PHN. Although a 30% improvement in pain is often an endpoint in clinical trials, some patients may require greater or less improvement in pain to be considered a clinical success.

CONCLUSIONS

The effectiveness results demonstrated that 8% capsaicin and topical lidocaine patches had significantly higher effectiveness rates than the oral agents used to treat PHN. In addition, this cost-effectiveness analysis found that the 8% capsaicin patch was similar to topical lidocaine patch and within an accepted cost per QALY gained threshold compared to the oral products.

A cost-utility comparison of four first-line medications in painful diabetic neuropathy

BACKGROUND

Painful diabetic neuropathy is common and adversely affects patients' quality of life and function. Several treatment options exist, but their relative efficacy and value are unknown.

OBJECTIVE

To determine the relative efficacy, costs and cost effectiveness of the first-line treatment options for painful diabetic neuropathy.

METHODS

Published and unpublished clinical trial and cross-sectional data were incorporated into a decision analytic model to estimate the net health and cost consequences of treatment for painful diabetic peripheral neuropathy over 3-month (base case), 1-month and 6-month timeframes. Efficacy was measured in QALYs, and costs were measured in $US, year 2006 values, using a US third-party payer perspective. The patients included in the model were outpatients with moderate to severe pain associated with diabetic peripheral neuropathy and no contraindications to treatment with tricyclic antidepressants. Four medications were compared: desipramine 100 mg/day, gabapentin 2400 mg/day, pregabalin 300 mg/day and duloxetine 60 mg/day.

RESULTS

Desipramine and duloxetine were both more effective and less expensive than gabapentin and pregabalin in the base-case analysis and through a wide range of sensitivity analyses. Duloxetine offered borderline value compared with desipramine in the base case ($US47,700 per QALY), but not when incorporating baseline-observation-carried-forward analyses of the clinical trial data ($US867,000 per QALY). The results were also sensitive to the probability of obtaining pain relief with duloxetine.

CONCLUSIONS

Desipramine (100 mg/day) and duloxetine (60 mg/day) appear to be more cost effective than gabapentin or pregabalin for treating painful diabetic neuropathy. The estimated value of duloxetine relative to desipramine depends on the assumptions made in the statistical analyses of clinical trial data.

A Cost-Effectiveness Comparison of Desipramine, Gabapentin, and Pregabalin for Treating Postherpetic Neuralgia

OBJECTIVES

To compare the net health effects and costs resulting from treatment with different first-line postherpetic neuralgia (PHN) medications.

DESIGN

Cost-utility analysis using published literature.

PARTICIPANTS

Hypothetical cohort of patients aged 60 to 80 with PHN.

INTERVENTIONS

Desipramine 100 mg/d, gabapentin 1,800 mg/d, and pregabalin 450 mg/d.

MEASUREMENTS

A decision model was designed to describe possible treatment outcomes, including different combinations of analgesia and side effects, during the first 3 months of therapy for moderate to severe PHN. The main outcome was cost per quality-adjusted life-year (QALY) gained. Costs were estimated using the perspective of a third-party payer. Multivariate, univariate, and probabilistic sensitivity analyses were performed, and the time frame of the model was varied to 1-month and 6-month horizons.

RESULTS

Desipramine was more effective and less expensive than gabapentin or pregabalin (dominant) under all conditions tested. Gabapentin was more effective than pregabalin but at an incremental cost of $216,000/QALY. Below $140/month, gabapentin became more cost-effective than pregabalin at a threshold of $50,000/QALY, and below $115/month gabapentin dominated pregabalin.

CONCLUSION

Desipramine appears to be more effective and less expensive than gabapentin or pregabalin for the treatment of older patients with PHN in whom it is not contraindicated. After its price falls, generic gabapentin will likely be more cost-effective than pregabalin.

Cost-efficacy of individual and combined treatments for panic disorder

OBJECTIVE

The objective of this study was to examine the relative cost-efficacy of empirically supported treatments for panic disorder. As psychosocial, pharmacologic, and combined treatments have all demonstrated efficacy in the treatment of panic disorder, cost-efficacy analysis provides an additional source of information to guide clinical decision making.

METHOD

Cost-efficacy was examined based on results from the Multicenter Comparative Treatment Study of Panic Disorder, a randomized controlled trial of treatment for panic disorder (DSM-III-R). The trial was conducted from May 1991 to April 1998. Cost-efficacy ratios representing the cost per 1-unit improvement in Panic Disorder Severity Scale mean item score were calculated for 3 monotherapies (cognitive-behavioral therapy [CBT], imipramine, and paroxetine) and 2 combination treatments (CBT-imipramine and CBT-paroxetine) at the end of acute, maintenance, and follow-up phases.

RESULTS

Results demonstrated consistently greater cost-efficacy for individual over combined treatments, with imipramine representing the most cost-efficacious treatment option at the completion of the acute phase (cost-efficacy ratio = $972) and CBT representing the most cost-efficacious option at the end of maintenance treatment (cost efficacy ratio = $1449) and 6 months after treatment termination (cost-efficacy ratio = $1227).

CONCLUSION

In the context of similar efficacy for combined treatments, but poorer cost-efficacy, current monotherapies should be considered the first-line treatment of choice for panic disorder. Additionally, CBT emerged as the most durable and cost-effective monotherapy and, hence, should be considered as a particularly valuable treatment from the perspective of cost accountability.

Analysis of antidepressant prescribing tendencies in Lithuania in 2003-2004

Depression is one of the leading causes of disability worldwide, affecting 121 million people in whole world. In many developed countries, the number of prescriptions for antidepressants increased steeply during the 1990s. The objective of the present study was to evaluate the antidepressant prescribing patterns in all regions of Lithuania during 2003-2004, to analyze the use within different antidepressant groups, and to examine trends in age- and gender-specific antidepressant use. Antidepressants were classified into three groups according to Anatomic Therapeutic Chemical (ATC) Classification specifying the defined daily doses. The results of our study show an increase in the use of reimbursed antidepressants except tricyclic in 2004 when compared to 2003. Increase in the use of selective serotonin reuptake inhibitors and other nontricyclic antidepressants is probably related to their better tolerability, improved risk-benefit ratio, and less toxicity in overdose. There was no increase in the percentage of consumed selective serotonin reuptake inhibitors in elderly patients when compared with younger ones, despite elderly patients are most likely to benefit from reduced sedation, less antimuscarinic and less cardiac toxicity of selective serotonin reuptake inhibitors. The prevalence of the antidepressant use is the highest among middle-aged people (40-59 years), while the young (under 20) and elderly (older than 70) patients receive mostly selective serotonin reuptake inhibitors. Additional studies should be carried out in order to assess drug-prescribing patterns in accordance with the guidelines of depression treatment in Lithuania considering diagnosis, dosage, and duration of treatment.

Effectiveness and cost-effectiveness of antidepressant treatment in primary health care: a six-month randomised study comparing fluoxetine to imipramine

BACKGROUND

Over the past decade, studies of the effectiveness of pharmacological treatment for depression have often been based on research designs intended to measure efficacy, and for this reason the results are of limited generalizability. Research is needed comparing the clinical and economic outcomes of antidepressants in day-to-day clinical practice.

METHODS

A six-month randomised prospective naturalistic study comparing fluoxetine to imipramine carried out in three primary care health centres. Outcome measures were the Montgomery Asberg Depression Rating Scale (MADRS), direct costs, indirect costs and total costs. Subjects were evaluated at the beginning of treatment and at one, three and six months thereafter.

RESULTS

Of the 103 patients, 38.8% (n = 40) were diagnosed with major depressive disorder, 14.6% (n = 15) with dysthymic disorder, and 46.6% (n = 48) with depressive disorder not otherwise specified. Patients with major depressive disorder or dysthymic disorder achieved similar clinical improvement in both treatment groups (mean MADRS ratings decrease in major depressive disorder from baseline to 6 months of 18.3 for imipramine and 18.8 for fluoxetine). For patients with major depressive disorder and dysthymic disorder, the imipramine group had fewer treatment-associated costs (imipramine 469.66 Euro versus fluoxetine 1,585.93 Euro in major depressive disorder, p < 0.05; imipramine 175.39 Euro versus fluoxetine 2,929.36 Euro in dysthymic disorder, p < 0.05). The group with depressive disorder not otherwise specified did not experience statistically significant differences in clinical and costs outcomes between treatment groups.

LIMITATIONS

Exclusion criteria, participating physicians may not represent GPs.

CONCLUSIONS

In a primary care context, imipramine may represent a more cost-effective treatment option than fluoxetine for treating major depressive disorder or dysthymic disorder. There were no differences in cost-effectiveness in the treatment of depressive disorder not otherwise specified.

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.

Trends in the consumption of antidepressant drugs in Lithuania in 2002-2004

OBJECTIVE

To evaluate trends in the use of antidepressant drugs in Lithuania between 2002 and 2004 and to perform cost-minimization and reference price analysis enabling more rational use of financial resources of national health system.

MATERIAL AND METHODS

The data on sales of antidepressant drugs in Lithuanian over a 3-year period (2002-2004) were obtained from IMS Health Inc. database. Data were calculated by defined daily dose (DDD) methodology and expressed in DDDs per 1000 inhabitants per day. DU90% was used as the quality indicator of the drug prescribing. The pharmacoeconomic analysis of antidepressant drugs was performed by cost-minimization and reference price methodology.

RESULTS

The consumption of antidepressants in Lithuanian increased by 30.55% over a 3-year period (2002-2004) reaching the value of 10.00 DDDs/1000 inhabitants/day. Since 2002, the proportion of use of selective serotonin reuptake inhibitors has increased by 27.82%, and the use of tricyclic antidepressants has declined by 10.78%, while the use of other (newer) antidepressant drugs expanded almost three times. The expenditures of antidepressant drugs have reached 26 million Lt in 2004, of which 68.15% were costs for selective serotonin reuptake inhibitors. Choosing the second lowest price in different antidepressant drug class, it is estimated the possible savings of 4.34 million Lt lowering the total expenses by 16.5% (1 euro=3.4528 Lt).

CONCLUSIONS

The findings suggest that the use of total antidepressant drugs continues to increase because of the increased use of selective serotonin reuptake inhibitors and other (newer) antidepressant drugs. In comparison with the data in other countries, the consumption of antidepressant drugs in Lithuania is low.

Does the use of SSRIs reduce medical care utilization and expenditures?

BACKGROUND

Although selective serotonin reuptake inhibitors (SSRIs) are more expensive than tricyclic antidepressants (TCAs), SSRIs may reduce overall health costs compared with TCAs through improved compliance and reduced need for other medical care services. Economic evaluation studies using clinical trial or claims data have not accurately estimated the actual costs associated with antidepressants because they did not appropriately address two issues: the heterogeneity of SSRI and TCA users and the use of antidepressants for non-indicated symptoms.

AIMS OF THE STUDY

This study estimates the relative substitution effect of SSRIs on the overall utilization of outpatient and inpatient care and other prescription drugs compared to TCAs. This study identifies and controls for heterogeneities in diagnosis among SSRI and TCA users and looks for variations in substitution effects across utilization.

METHODS

To estimate the direct effect of SSRIs compared with TCAs on the utilization of other medical care resources in a naturalistic setting, this study uses the Medical Expenditure Panel Survey, national panel survey data, from 1996 to 1998. The main model of analysis is a two-part regression: the first part is a probit model of any use and the second part is a log linear model of expenditures among users. Baseline physical health status, depression severity, and socioeconomic factors that could affect antidepressant choice and medical care utilization are controlled for.

RESULTS

A considerable fraction of antidepressant use, especially among TCA users, is for reasons other than depression. After controlling for the heterogeneity in SSRI and TCA users, this study does not find consistent evidence of the substitution of SSRIs for other medical care. Although SSRIs, compared with TCAs, reduce overall outpatient visits and other prescription drugs, they increase the utilization of these services for depression. Antidepressant choice does not influence the utilization or expenditure level for inpatient services which composed the largest part of medical expenditure in this study sample. Results are robust when the analysis is restricted to the SSRI or TCA users with a depression diagnosis.

DISCUSSION

The potential cost-incremental effect of SSRIs over TCAs for the treatment of depression can be compromised by the reduced utilization for symptoms other than depression among SSRI users. This study uses national survey data and takes into account the heterogeneity of SSRI and TCA users so the results can be generalized to real clinical practice.

IMPLICATIONS FOR HEALTH CARE PROVISION

The costs associated with antidepressants are not only for the treatment of depression symptoms. Antidepressants are commonly prescribed for conditions for which the clinical and economic benefits are not established. This practice may lead to significant unnecessary healthcare expenses.

IMPLICATIONS FOR HEALTH POLICIES

Antidepressant prescriptions for non-indicated conditions should be considered in setting policies designed to control costs associated with antidepressants and in developing clinical guidelines for antidepressant prescription.

IMPLICATIONS FOR FUTURE RESEARCH

Future research on the economic evaluation of antidepressants should consider the use of antidepressants for health conditions other than depression. The economic incentives for and clinical benefits of the prescription of antidepressants for non-indicated conditions could be explored in future research.

A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine

OBJECTIVE

To determine the relative cost-effectiveness of three classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and the modified TCA lofepramine, as first choice treatments for depression in primary care.

DESIGN

Open, pragmatic, controlled trial with three randomised arms and one preference arm. Patients were followed up for 12 months.

SETTING

UK primary care: 73 practices in urban and rural areas in England.

PARTICIPANTS

Patients with a new episode of depressive illness according to GP diagnosis.

INTERVENTIONS

Patients were randomised to receive a TCA (amitriptyline, dothiepin or imipramine), an SSRI (fluoxetine, sertraline or paroxetine) or lofepramine. Patients or GPs were able to choose an alternative treatment if preferred.

MAIN OUTCOME MEASURES

At baseline the Clinical Interview Schedule, Revised (CIS-R PROQSY computerised version) was administered to establish symptom profiles. Outcome measures over the 12-month follow-up included the Hospital Anxiety and Depression Scale self-rating of depression (HAD-D), CIS-R, EuroQol (EQ-5D) for quality of life, Short Form (SF-36) for generic health status, and patient and practice records of use of health and social services. The primary effectiveness outcome was the number of depression-free weeks (HAD-D less than 8, with interpolation of intervening values) and the primary cost outcome total direct NHS costs. Quality-adjusted life-years (QALYs) were used as the outcome measure in a secondary analysis. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were computed. Estimates were bootstrapped with 5000 replications.

RESULTS

In total, 327 patients were randomised. Follow-up rates were 68% at 3 months and 52% at 1 year. Linear regression analysis revealed no significant differences between groups in number of depression-free weeks when adjusted for baseline HAD-D. A higher proportion of patients randomised to TCAs entered the preference arm than those allocated to the other choices. Switching to another class of antidepressant in the first few weeks of treatment occurred significantly more often in the lofepramine arm and less in the preference arm. There were no significant differences between arms in mean cost per depression-free week. For values placed on an additional QALY of over 5000 pounds, treatment with SSRIs was likely to be the most cost-effective strategy. TCAs were the least likely to be cost-effective as first choice of antidepressant for most values of a depression-free week or QALY respectively, but these differences were relatively modest.

CONCLUSIONS

When comparing the different treatment options, no significant differences were found in outcomes or costs within the sample, but when outcomes and costs were analysed together, the resulting cost-effectiveness acceptability curves suggested that SSRIs were likely to be the most cost-effective option, although the probability of this did not rise above 0.6. Choosing lofepramine is likely to lead to a greater proportion of patients switching treatment in the first few weeks. Further research is still needed on the management of depressive illness in primary care. This should address areas such as the optimum severity threshold at which medication should be used; the feasibility and effectiveness of adopting structured depression management programmes in the UK context; the importance of factors such as physical co-morbidity and recent life events in GPs' prescribing decisions; alternative ways of collecting data; and the factors that give rise to many patients being reluctant to accept medication and discontinue treatment early.

Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder

OBJECTIVE

To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]).

METHOD

The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Wellbeing, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12 000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater.

CONCLUSIONS

Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.

Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Panic Disorder and Agoraphobia. Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority.

METHOD

For these guidelines, the CPG team reviewed the treatment outcome literature, consulted with practitioners and patients and conducted a meta-analysis of recent outcome research.

TREATMENT RECOMMENDATIONS

Education for the patient and significant others covering: (i) the nature and course of panic disorder and agoraphobia; (ii) an explanation of the psychopathology of anxiety, panic and agoraphobia; (iii) rationale for the treatment, likelihood of a positive response, and expected time frame. Cognitive behaviour therapy (CBT) is more effective and more cost-effective than medication. Tricyclic antidepressants (TCAs) and serotonin selective reuptake inhibitors are equal in efficacy and both are to be preferred to benzodiazepines. Treatment choice depends on the skill of the clinician and the patient's circumstances. Drug treatment should be complemented by behaviour therapy. If the response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used. A second opinion can be useful. The presence of severe agoraphobia is a negative prognostic indicator, whereas comorbid depression, if properly treated, has no consistent effect on outcome.

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.

WCA recommendations for the long-term treatment of obsessive-compulsive disorder in adults

What are the latest psychotherapeutic and pharmacotherapeutic treatment recommendations for obsessive-compulsive disorder (OCD)? OCD is a relatively common disorder with a lifetime prevalence of approximately 2% in the general population. It often has an early onset, usually in childhood or adolescence, and frequently becomes chronic and disabling if left untreated. High associated healthcare utilization and costs, and reduced productivity resulting in loss of earning, pose a huge economic burden to OCD patients and their families, employers, and society. OCD is characterized by the presence of obsessions and compulsions that are time-consuming, cause marked distress, or significantly interfere with a person's functioning. Most patients with OCD experience symptoms throughout their lives and benefit from long-term treatment. Both psychotherapy and pharmacotherapy are recommended, either alone or in combination, for the treatment of OCD. Cognitive-behavioral therapy is the psychotherapy of choice. Pharmacologic treatment options include the tricyclic antidepressant clomipramine and the selective serotonin reuptake inhibitors (SSRIs) citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. These have all shown benefit in acute treatment trials; clomipramine, fluvoxamine, fluoxetine, and sertraline have also demonstrated benefit in long-term treatment trials (at least 24 weeks), and clomipramine, sertraline, and fluvoxamine have United States Food and Drug Administration approvals for use in children and adolescents. Available treatment guidelines recommend first-line use of an SSRI (ie, fluoxetine, fluvoxamine, paroxetine, sertraline, or citalopram) in preference to clomipramine, due to the latter's less favorable adverse-event profile. Further, pharmacotherapy for a minimum of 1-2 years is recommended before very gradual withdrawal may be considered.

An analysis of the diffusion of new antidepressants: variety, quality, and marketing efforts

BACKGROUND

We are not aware of any published research that quantifies and compares the importance of effectiveness and side effects for pharmaceutical sales, and that simultaneously incorporates the impacts of marketing efforts on the diffusion of new pharmaceutical agents in the U.S. The overall level and market share success of the various selective serotonin reuptake inhibitors ( SSRIs ) relative to a representative older generation tricyclic (such as amitriptyline) provides a useful focus for studying such issues.

AIMS OF STUDY

To model jointly the marketing and sales relationships of the SSRIs in the U.S., to quantify the extent to which marketing efforts are responsive to the availability of new scientific information accompanying changes in quality and increases in product variety, and in turn to assess how the new FDA indication approvals and the enhanced marketing initiatives involving product quality and variety affect sales of the SSRI and other novel antidepressants.

METHODS

Quarterly US sales, price, quantity and marketing data 1988Q1-1997Q4 are taken from IMS Health for the eight new antidepressants introduced into the US during this time period. Measures of physician-perceived quality attributes of the antidepressants are drawn from Market Measures, Inc., a medical survey research firm. These data are used to construct measures of product quality (effectiveness and side effect profile), and attribute variety across all antidepressants. Multivariate regression methods are used in estimating parameters of a marketing efforts model, a sales demand model encompassing the aggregate of the newer antidepressants, and a product share model. Simulation methods are employed to quantify elasticities.

RESULTS

Since 1988, and relative to amitriptyline, there has been only a rather modest increase in the perceived average effectiveness of the SSRIs and related products, but the side effect profiles have improved substantially. Variety measures for effectiveness show greater increases over time than do those for side effects. Marketing efforts respond to science-based events, such as new FDA indication approvals, and to effectiveness and side-effect quality improvements. Total antidepressant sales are positively and significantly related to price reductions, increased marketing efforts, and the level and variety of side effect profiles involving antidepressants. The level and variety of effectiveness does not significantly affect total antidepressant sales. Order of entry effects are important in affecting product market shares, while marketing efforts and relative quality attributes (particularly a more favorable side effect profile) have positive and significant impacts on relative market shares.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Since patient response to SSRIs and related products is idiosyncratic, greater product variety facilitates better matching of antidepressant with patient. Much of the growth of the SSRIs and related antidepressants since 1988 can be attributed to increased product attribute variety, to improved changes in side effect quality relative to that of the tricyclics, and to the marketing of those improvements.

IMPLICATIONS FOR HEALTH POLICIES

Marketing efforts play an important role in diffusing product information. Marketing efforts increase considerably following FDA approval for indications other than depression, and also increase with the average effectiveness and the average side effect rating of the products.

IMPLICATIONS FOR FURTHER RESEARCH

Whether the relatively minor role that perceived effectiveness has in affecting sales relative to perceived side effect profile is unique to antidepressants, or generalizes to other therapeutic classes, merits further examination.

Retrospective analysis of the health-care costs of bupropion sustained release in comparison with other antidepressants

OBJECTIVE

The objective of this study was to evaluate the health care costs associated with the treatment of a new episode of depression with bupropion sustained release (SR) rather than with other antidepressants (selective serotonin reuptake inhibitors [SSRIs], tricyclic antidepressants [TCAs], and serotonin norepinephrine reuptake inhibitors [SNRIs]).

METHODS

This was a retrospective cohort study based on the private-pay, fee-for-service 1997 and 1998 MEDSTAT MarketScan databases. Individuals were included if they were 18 years of age or older, had an initial prescription for an antidepressant under study with an index prescription date between July 1997 and June 1998, and had a claim for a diagnosis of depression diagnosis within 30 days of the index date. All patients' claims from six months before and after receiving their index antidepressant prescription were examined. Total, outpatient, and pharmacy costs were compared among antidepressant groups using an intent-to-treat analysis with exponential regression models and bootstrapped 95% confidence intervals.

RESULTS

A total of 1771 patients were included in the study cohort. The mean age was 41.6 years, and 69.5% of subjects were female. Most patients (75%) continued with the index antidepressant during the 6-month follow-up period. Although the drug acquisition cost was lowest for TCAs, total costs were significantly higher for patients treated with TCAs than for those treated with bupropion SR (p < .05). In comparison with bupropion SR, patients initiating therapy with sertraline had significantly higher mental health payments (p < .05).

CONCLUSIONS

Initiating treatment of depression with bupropion SR was associated with lower total mental health care costs compared with TCAs and with sertraline. This study reaffirms that formulary and medical decision-makers should consider the overall impact of antidepressant treatment, including but not limited to drug acquisition costs, other health care costs, and drug efficacy and safety.

The pharmacoeconomics of venlafaxine in depression

The prevalence of depression and the high costs associated with its management have heightened interest in pharmacoeconomic evaluation of drug treatment, especially the use of selective serotonin reuptake inhibitors (SSRIs) and the serotonin-norepinephrine reuptake inhibitor venlafaxine. A number of studies of venlafaxine in both inpatient and outpatient settings have revealed that extended-release venlafaxine has a lower expected cost than comparable treatment with SSRIs and tricyclic antidepressants (TCAs). When the relative cost effectiveness of immediate-release venlafaxine, SSRIs, and TCAs was assessed in the treatment of major depressive disorder in 10 countries, venlafaxine yielded a lower than expected cost compared with SSRIs and TCAs in all but 1 country. In comparing healthcare expenditures for depressed patients with and without anxiety, there was a pharmacoeconomic benefit to both immediate- or extended-release venlafaxine, regardless of the presence or absence of comorbid anxiety. A review of computerized administrative claims data from 9 US healthcare plans on resource use and the cost of venlafaxine instead of TCAs after switching from an SSRI showed that overall costs did not vary markedly between venlafaxine and TCAs. This led to the conclusion that although therapy with venlafaxine is more costly than TCA therapy, this increase may be offset by lower costs of other medical services. Such findings have enormous potential ramifications for practicing physicians in terms of venlafaxine's superior remission rate, lower likelihood of relapse, loss of fewer patients to adverse events or lack of efficacy, and flexibility in dosing that enables titration to achieve an optimal response.

A record-based analysis of 803 patients treated for depression in psychiatric care

BACKGROUND

New antidepressants emerged and became widely used during the 1990s. The present study investigated quality-of-care problems in the treatment of depression in a current psychiatric setting.

METHOD

We investigated the treatment received for depression by all 803 inpatients or outpatients with a clinical diagnosis of ICD-10 depressive episode or recurrent depressive disorder in 1996 in the Peijas Medical Care District, which provides psychiatric services for citizens of Vantaa, a city in southern Finland.

RESULTS

Most patients (84%) in the sample were found to have received antidepressants, generally in adequate, albeit low, doses. Inadequate antidepressant treatment was common only with tricyclic antidepressants. Most patients received a single antidepressant for extended periods; only 22% had 2 or more antidepressant trials. During the treatment period, disability pension was granted to 19% of those not already pensioned, two thirds (67%) of whom had received only 1 antidepressant trial prior to being granted a pension.

CONCLUSION

The present study supports the emerging perception of improved quality of pharmacotherapy in psychiatric settings, with the exception of treatment with tricyclic antidepressants. Problems of quality of care now appear to be related to the suboptimal intensity and monitoring of the treatment provided. which may eventually result in considerable costs to society due to permanent disability.

Assessment of clinical guidelines for continuation treatment in major depression

OBJECTIVE

The primary objective of this study was to assess the appropriateness of the existing Dutch clinical guidelines for the treatment of depression from a health-economic perspective. The existing guidelines recommend continuation treatment for a period up to 9 months.

METHODS

The assessment was based on a Markov model using decision-analytic techniques. For this analysis we defined six mutually exclusive states defined by the existence of depression and type of treatment. The outcomes for the model were defined as: time without depression (TWD), quality-adjusted life years (QALYs), direct medical costs, and cost of lost productivity. The primary perspective of the study was that of the third-party payer, while the secondary perspective was that of the society in 1999. The probabilities of clinical events and therapeutic choices as well as the utilities were based on published literature. The medical resource use related to each state was abstracted from published literature and expert opinion. The associated 1999 unit costs of the used medical resources were derived from official Dutch tariff lists of allowable reimbursements. Indirect costs in this model were based on lost productivity only.

RESULTS

The results of the primary analysis showed that the use of the guidelines is not cost-effective. Continuation treatment for a period of 9 months increases the total direct medical costs (NLG 1276 vs. NLG 474), decreases the costs resulting from lost productivity (NLG 304 vs. NLG 909), increases total costs (NLG 1580 vs. NLG 1383) and increases TWD (96.9% vs. 86.4%). However, continuation treatment does not change the utility outcomes (0.60 vs. 0.61 QALYs) for both treatment strategies. Hence continuation treatment is not cost-effective from either a third-party payer perspective or a societal perspective. A scenario analysis showed that an extension of the continuation treatment to maintenance treatment might result in a favorable cost-effectiveness outcome of the treatment guideline.

CONCLUSION

In conclusion, based on the assumptions used in the model, the current Dutch treatment guidelines for depression are only appropriate from a health-economic perspective if continuation treatment is extended to maintenance treatment.

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.

A multinational pharmacoeconomic evaluation of acute major depressive disorder (MDD): a comparison of cost-effectiveness between venlafaxine, SSRIs and TCAs

METHODS

We conducted a multinational pharmacoeconomic evaluation comparing the immediate release form of a new class of serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine IR to the selective serotonin reuptake inhibitors (SSRIs) and the tricyclic antidepressants (TCAs) in the treatment of acute major depressive disorder (MDD) in 10 countries (Germany, Italy, Netherlands, Poland, Spain, Sweden, Switzerland, United Kingdom, United States, and Venezuela). We designed a decision analytic model assessing the acute phase of MDD treatment within a 6-month time horizon. Six decision tree models were customized with country-specific estimates from a clinical management analysis, meta-analytic rates from two published meta-analyses, and a resource valuation of treatment costs representing the inpatient and outpatient settings within each country. The meta-analyses provided the clinical rates of success defined as a 50% reduction in depression scores on the Hamilton Depression Scale (HAM-D) or the Montgomery-Asberg Depression Rating Scale (MADRS). Treatment regimen costs were determined from standard lists, fee schedules, and communication with local health economists in each country. The meta-analytic rates were applied to the decision analytic model to calculate the expected cost and expected outcomes for each antidepressant comparator. Cost-effectiveness was determined using the expected values for both a successful outcome, and a composite measure of outcome termed symptom-free days. A policy analysis was conducted to examine the health system budget impact in each country of increasing the utilization of the most effective antidepressant found in our study.

RESULTS

Initiating treatment of MDD with venlafaxine IR yielded a lower expected cost compared to the SSRIs and TCAs in all countries except Poland in the inpatient setting, and Italy and Poland within the outpatient settings. The weighted average expected cost per patient varied from US$632 (Poland) to US$5647 (US) in the six-month acute phase treatment of MDD. The estimated total budgetary impact for each 1% of venlafaxine utilization, assuming a population of one million MDD patients, ranged from US$1600 (Italy) to US$29,049 (US).

CONCLUSIONS

Within the inpatient and outpatient treatment settings, venlafaxine IR was a more cost-effective treatment of MDD compared to the SSRIs and TCAs. Additionally, the results of this investigation indicate that increased utilization of venlafaxine in most settings across Europe and the Americas will have favorable impact on health care payer budgets. ADR, adverse drug reaction; CMA, clinical management analysis; ECT, electroconvulsive therapy; HAM-D, Hamilton Depression Scale; MADRS, Montgomery-Asberg depression rating scale; MDD, major depressive disorder; SFD, symptom-free day; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; WHO, world health organization.

Cost-benefit analysis of newer versus older antidepressants--pharmacoeconomic studies comparing SSRIs/SNRIs with tricyclic antidepressants

Changes in the social and health services over the last years have forced doctors to concern themselves with cost benefit calculations and budget forecasting. Cost considerations are a (co-) determinant in the choice of antidepressants as well as neuroleptics and/or antipsychotics. In recent years, pharmacoeconomic studies have been performed to answer the question as to what extent treatment with new antidepressants, in particular SSRIs, is actually less expensive than treatment with (generic) tricyclic antidepressants due to better safety profiles and higher compliance in spite of the considerably higher retail price. Following descriptions of the methodological principles, the currently available studies are presented and discussed critically in this report. It can be stated that the economic value of different antidepressants can not be decided definitively at the present time. The available data do not allow the conclusion that SSRIs should be preferred over tricyclic antidepressants with the argument that the treatment as a whole is more cost effective in spite of the higher costs.

Mirtazepine: heir apparent to amitriptyline?

"What's new in therapeutics?" will examine and evaluate drugs that may have a place in hospice, palliative, and long-term care. Mirtazepine will be examined and evaluated. Mirtazepine is a potential alternative anti-depressant with multiple additional benefits. It is an atypical anti-depressant, which has both noradrenergic and specific serotonergic receptor antagonism (NaSSa), and a unique pharmacological profile. Mirtazepine appears to be a "designer drug" for palliative medicine with a number of benefits, but cost may be a drawback.

Deliberate self poisoning with antidepressant drugs: a comparison of the relative hospital costs of cases of overdose of tricyclics with those of selective-serotonin re-uptake inhibitors

BACKGROUND

Debate continues over the relative merits of tricyclics and selective serotonin re-uptake inhibitors (SSRIs) as first line antidepressant treatment for depression. SSRIs are safer in overdose but more expensive than tricyclics. This report compared the hospital costs of cases of overdose with both groups of drug.

METHODS

Records of all persons aged over thirteen years presenting to a general hospital in one year were analysed for demographic information and details of their attendance.

RESULTS

There were 1165 episodes of self-poisoning, 151 involving tricyclics as the sole antidepressant and 69 SSRIs as the sole antidepressant. Those taking SSRIs had a shorter (1.96 vs. 2.59 days) and less expensive ( pound330 vs. pound567) stay. A large proportion of this difference in cost was due to a small number of admissions to the Intensive Care Unit.

LIMITATIONS

This study used only hospital costs, so excluding costs associated with primary care.

CONCLUSIONS AND CLINICAL RELEVANCE

If there were similar cost differences countrywide, the difference in hospital costs of self poisoning with SSRIs and tricyclics would represent an additional pound3.87 million per year due to self poisoning with tricyclics across the whole of England and Wales. This is a small proportion of the estimated pound100 million cost of switching to first-line prescribing of SSRIs for depression.

Economic impact of using mirtazapine compared to amitriptyline and fluoxetine in the treatment of moderate and severe depression in the UK

This study modelled the economic impact of mirtazapine, compared to amitriptyline and fluoxetine, in the management of moderate and severe depression in the UK, as well as the costs related to discontinuation of antidepressant treatment. Decision models of the management of moderate and severe depression were developed from clinical trial data, resource use obtained from interviews with general practitioners and psychiatrists, and published literature, and were used to estimate the expected direct National Health Service (NHS) costs of managing a patient with moderate or severe depression. The expected cost of healthcare resource use attributable to managing a patient suffering from moderate or severe depression who discontinues antidepressant treatment, irrespective of the initial treatment, was estimated to be pounds sterling 206 (range pounds sterling 50 to pounds sterling 504) over five months. Using mirtazapine instead of amitriptyline for seven months increases the proportion of successfully treated patients by 21% (from 19.2 to 23.2%) and reduces the expected direct NHS cost by pounds sterling 35 per patient (from pounds sterling 448 to pounds sterling 413). Using mirtazapine instead of fluoxetine for six months increases the proportion of successfully treated patients by 22% (from 15.6 to 19.1%), albeit for an additional cost to the NHS of pounds sterling 27 per patient (from pounds sterling 394 to pounds sterling 420). In conclusion, this study suggests that mirtazapine is a cost-effective antidepressant compared to amitriptyline and fluoxetine in the management of moderate and severe depression in the UK.

Health economic evaluations of antidepressants: a review

In an era of constrained health care financing, clinicians are increasingly faced with considering the economic consequences in addition to the clinical outcomes associated with initiating a patient on antidepressant therapy. This has increased the demand for health economic studies comparing antidepressant use and associated health care expenditures in clinical practice. These health economics studies have used methods ranging from clinical trials to other types of analyses including prospective naturalistic trials or retrospective studies which may be less familiar to clinicians. Prospective and retrospective health economics studies performed in clinical practice complement the experience gained from clinical trials in assessing antidepressant use and economic outcomes in light of patient and provider behavior within the usual care environment of a complex health care system. Broadly considered, health economic studies of antidepressants have consistently found differences in clinical practice between the tricyclic antidepressants (TCAs) and the selective serotonin reuptake inhibitors (SSRIs) as well as among the SSRIs. These differences relate to the pattern and duration of antidepressant use as well as total direct health care expenditures. Future health economic research studies in clinical practice should focus on the economic consequences of long-term antidepressant use as well as the impact of antidepressant use on indirect costs such as productivity and absenteeism.

[Treatment of depression and cost efficiency. The cost of a tablet is a poor indicator seen from a socioeconomic perspective]

Direct costs for treating depression, i.e. the cost of out-patient and in-patient care together with drug costs, have increased by 55 per cent during the period 1987-1997 in Sweden. Drugs incurred the greatest increase, whereas the cost of in-patient care has decreased. Indirect costs, i.e. sick leave, morbidity and premature mortality due to depression, have also increased during this period. Cost-effectiveness calculations comparing mirtazapine with amitriptyline show that it is less expensive to initiate treatment with mirtazapine, both when direct costs are compared and when indirect costs are included. In a comparison between mirtazapine and fluoxetine, initial treatment with fluoxetine is less expensive with respect to direct cost, but these two alternatives are equivalent when indirect costs are taken into consideration. The price of drug is a poor criterion of resource expenditures and of rational pharmacological therapy in the treatment of depression.

One-year costs of second-line therapies for depression

BACKGROUND

We compared patterns of medical resource utilization and costs among patients receiving a serotonin-norepinephrine reuptake inhibitor (venlafaxine), one of the selective serotonin reuptake inhibitors (SSRIs), one of the tricyclic agents (TCAs), or 1 of 3 other second-line therapies for depression.

METHOD

Using claims data from a national managed care organization, we identified patients diagnosed with depression (ICD-9-CM criteria) who received second-line antidepressant therapy between 1993 and 1997. Second-line therapy was defined as a switch from the first class of antidepressant therapy observed in the data set within 1 year of a diagnosis of depression to a different class of antidepressant therapy. Patients with psychiatric comorbidities were excluded.

RESULTS

Of 981 patients included in the study, 21% (N = 208) received venlafaxine, 34% (N = 332) received an SSRI, 19% (N = 191) received a TCA, and 25% (N = 250) received other second-line antidepressant therapy. Mean age was 43 years, and 72% of patients were women. Age, prescriber of second-line therapy, and prior 6-month expenditures all differed significantly among the 4 therapy groups. Total, depression-coded, and non-depression-coded 1-year expenditures were, respectively, $6945, $2064, and $4881 for venlafaxine; $7237, $1682, and $5555 for SSRIs; $7925, $1335, and $6590 for TCAs; and $7371, $2222, and $5149 for other antidepressants. In bivariate analyses, compared with TCA-treated patients, venlafaxine- and SSRI-treated patients had significantly higher depression-coded but significantly lower non-depression-coded expenditures. Venlafaxine was associated with significantly higher depression-coded expenditures than SSRIs. However, after adjustment for potential confounding covariables in multivariate analyses, only the difference in depression-coded expenditures between SSRI and TCA therapy remained significant.

CONCLUSION

After adjustment for confounding patient characteristics, 1-year medical expenditures were generally similar among patients receiving venlafaxine, SSRIs, TCAs, and other second-line therapies for depression. Observed differences in patient characteristics and unadjusted expenditures raise questions as to how different types of patients are selected to receive alternative second-line therapies for depression.

Effect of antidepressant choice on the incidence and economic intensity of hospitalization among depressed individuals

This study identified differences in hospital utilization for mental health problems among depressed patients initially treated with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs). A retrospective sample of 2,557 patients was obtained from a private insurance claims database. Quasi-experimental, two-stage multivariate regression modeling was used to estimate the likelihood of hospitalization and subsequent inpatient expenditures. Only 2% of the sample were hospitalized, and the average expenditures per admitted patient was about $8,000. Patients initially prescribed sertraline had the same likelihood of hospitalization for a mental health problem as patients prescribed TCAs. Patients initially prescribed fluoxetine were half as likely to be hospitalized as patients initially prescribed TCAs. Once hospitalized, no differential effects of a specific antidepressant on inpatient expenditures were found.

Use of antidepressants among elderly subjects: trends and contributing factors

OBJECTIVE

The authors assessed changes over time in antidepressant utilization among elderly subjects regarding the prevalence of antidepressant users, shifts in prescription patterns, and related financial implications.

METHOD

The authors conducted a population-based study of more than 1.4 million Ontario residents aged 65 years or older. Cross-sectional data regarding annual antidepressant utilization were obtained from administrative databases for 1993 to 1997. Time series analysis was used to assess trends over time and to make future projections.

RESULTS

The proportion of antidepressant users increased from 9.3% of the elderly population in 1993 to 11.5% in 1997. Prescriptions for selective serotonin reuptake inhibitors (SSRIs) accounted for 9.6% of antidepressant prescriptions dispensed in the first 30 days of 1993 and 45.1% of those dispensed by the last 30 days of 1997 and were projected to increase to approximately 56% by the end of 2000. Prescriptions for tricyclic antidepressants fell from 79.0% in the first 30 days of 1993 to 43.1% by the last 30 days of 1997 and were projected to decline to approximately 28% by the end of 2000. Annual antidepressant costs (in Canadian dollars) increased by 150%, from $10.8 million in 1993 to $27.0 million in 1997. Population shifts and an increase in the prevalence of antidepressant users accounted for at least 20% of this increase, whereas the prescribing transition from tricyclic antidepressants to SSRIs accounted for at least 61% of the increase.

CONCLUSIONS

The introduction of SSRIs has had a substantial financial impact at the drug utilization level. Future research should address the appropriate balancing of the cost of newer agents versus their ostensible advantages.

Economic appraisal of citalopram in the management of single-episode depression

A retrospective intent-to-treat analysis (N = 1,339) was conducted to discern the natural course of antidepressant use and direct health service expenditures for the treatment of single-episode depression (DSM-IV code 296.20) among patients initiating antidepressant pharmacotherapy with either a tricyclic antidepressant (TCA) (amitriptyline, N = 237) or a selective serotonin reuptake inhibitor (SSRI) (citalopram, N = 71; fluoxetine, N = 411; paroxetine, N = 334; or sertraline, N = 286). Data were derived from the computer archive of a network-model health maintenance organization for the period of January 1, 1996, through April 30, 1999. Comparisons at the end of the 6-month post-period (180 days) were undertaken between cohorts initiating antidepressant pharmacotherapy with citalopram and each SSRI or TCA. Consistent with the intent-to-treat design, all accrued health service expenditures were assigned to the pharmacotherapeutic option initially prescribed. Multivariate models were adjusted for patient's age, gender, number of concomitant disease state processes, use of health services in the 6-month time frame (180 days) before initiating antidepressant pharmacotherapy, specialty of physician recording a diagnosis of single-episode depression, and the presence or absence of a previous diagnosis of single-episode depression and receipt of antidepressant pharmacotherapy. Patients initiating antidepressant pharmacotherapy with citalopram were far more likely to (1) have been diagnosed by a psychiatrist (37%; p < or = 0.05); (2) continue with the original pharmacotherapeutic option (79%) compared with patients originally prescribed amitriptyline (51%; chi2 = 17.29, df = 1, p < or = 0.05) or sertraline (65%; chi2 = 36.91, df = 1, p < or = 0.05); no significant difference was found compared with patients initiating antidepressant pharmacotherapy with paroxetine (72%; p = not significant [NS]) or fluoxetine (83%; p = NS); (3) obtain 90 days or more of antidepressant pharmacotherapy (86%) compared with those prescribed amitriptyline (69%; chi2 = 8.09, df = 1, p < or = 0.05); no significant difference was found compared with sertraline (77%), paroxetine (81%), or fluoxetine (84%); and (4) obtain 6 months (180 days) of antidepressant pharmacotherapy (68%) compared with those prescribed amitriptyline (39%; chi2 = 18.26, df = 1, p < or = 0.05) or sertraline (51%; chi2 = 6.02, df = 1, p < or = 0.05); no significant difference was found compared with paroxetine (56%) or fluoxetine (59%). Receipt of amitriptyline or sertraline as initial medication was associated with a per capita increase (p < or = 0.05) in health service utilization (17% and 9%, respectively) relative to citalopram. No significant difference (p > 0.05) in health service utilization was discerned between citalopram and either fluoxetine or paroxetine. Multivariate models adjusted for nonrandom assignment to the initial pharmacotherapeutic option confirmed these findings. Further research over a longer time course is warranted.

Costs of antidepressant overdose: a preliminary study

There is ongoing debate regarding the relative cost effectiveness of different classes of antidepressants. Although factors such as tolerability and discontinuation rates have been taken into account, there has been little consideration of the cost of overdose. In the current study we examined the cost of antidepressant overdose at four teaching hospitals over a four-week period and found that the cost of selective serotonin reuptake inhibitor overdose was less than half that of tricyclic anti-depressant overdose. The cost of overdose is often ignored and should be considered in future analyses of the cost effectiveness of different antidepressant prescribing policies in primary care.

Cost-effectiveness of mirtazapine compared to amitriptyline and fluoxetine in the treatment of moderate and severe depression in austria

This study estimated the cost-effectiveness of mirtazapine, compared to amitriptyline and fluoxetine, in the management of moderate and severe depression in Austria, as well as the costs related to the discontinuation of antidepressant treatment from the perspective of the Austrian Sick Funds (Gebietskrankenkassen). The economic analyses were based on a meta-analysis of four randomised clinical trials comparing mirtazapine with amitriptyline, and on a six week comparative trial of mirtazapine and fluoxetine which was extrapolated to six months using assumptions derived from the literature. Decision models of the treatment paths and associated resource use attributable to managing moderate and severe depression in Austria were developed from clinical trial data, information on Austrian clinical practice obtained from interviews with an Austrian Delphi panel (comprising psychiatrists and GPs), and from published literature. The models were used to estimate the expected costs to the Gebietskrankenkassen of managing a patient with moderate or severe depression, and the indirect cost per patient to Austrian society due to lost productivity. The expected cost to the Gebietskrankenkassen of healthcare resource use attributable to managing a patient suffering from moderate or severe depression who discontinues antidepressant treatment was estimated to be ATS 4,088 over five months, of which hospitalisations accounted for nearly 69% of the cost. Using mirtazapine instead of amitriptyline for 28 weeks increases the proportion of successfully treated patients by 21% (from 19.2 to 23.2%), and reduces the expected cost to the Gebietskrankenkassen by ATS 1,112 per patient (from ATS 31,411 to ATS 30,299). Patients treated with mirtazapine and amitriptyline for 28 weeks are expected to miss 4.76 and 5.01 weeks of work respectively, due to their depression. Hence, the expected indirect cost to Austrian society over this period was estimated to be ATS 58, 787 and ATS 61,851 per patient respectively. Using mirtazapine instead of fluoxetine for six months increases the proportion of successfully treated patients by 22% (from 15.6 to 19.1%), albeit for a negligible additional cost to the Gebietskrankenkassen of ATS 408 per patient (from ATS 29,205 to ATS 29,613). Patients treated with mirtazapine and fluoxetine for six months are expected to miss 4.53 weeks of work, due to their depression. Hence, the expected indirect cost to Austrian society due to lost productivity was estimated to be ATS 55,900 per patient with either antidepressant. In conclusion, this study suggests that despite the differences in acquisition costs, mirtazapine is a cost-effective antidepressant compared to amitriptyline and fluoxetine, supporting the adoption of this treatment in the management of moderate and severe depression in Austria.

Comparison of the cost-effectiveness of milnacipran (a SNRI) with TCAs and SSRIs: a modeling approach

A simulation model based on the theory of clinical decision analysis was used to compare outcomes and costs when treating patients with major depressive episodes using either a selective serotonin re-uptake inhibitor (SSRI) or a tricyclic antidepressant (TCA), in comparison with milnacipran (a serotonin), and a norepinephrine re-uptake inhibitor (SNRI). The clinical data used were taken from published meta-analyses. This analysis supports: (1) a comparable efficacy of milnacipran and TCA with a better tolerance; and, (2) an advantage of milnacipran over SSRI for efficacy with a comparable tolerance. Based on these findings, a decision tree was constructed with the assistance of a panel of psychiatrists in order to provide a model of usual clinical practice. Estimates not available from clinical studies were obtained either from literature analysis or from the panel. Economic appraisal was performed according to the viewpoint of the French national sickness fund (sécurité sociale), and expenditure assessment was limited to direct costs (hospitalizations, antidepressant medications, visits, and laboratory tests). The results suggest that milnacipran is a cost-effective alternative: the expected cost of treatment per depressive episode is lower than either a French representative panel of TCAs (a saving of 288 FF), or SSRIs (a savings of 961 FF). The expected length of clinical remission is slightly higher than comparators. The robustness of these findings was supported by sensitivity analyses.

Medical resource use and cost of venlafaxine or tricyclic antidepressant therapy. Following selective serotonin reuptake inhibitor therapy for depression

OBJECTIVE

An analysis of administrative and claims data was performed to compare the resource use and costs to a managed-care organisation of venlafaxine, a serotonin and norepinephrine reuptake inhibitor (SNRI), versus tricyclic antidepressant (TCA) therapy, after switching from a selective serotonin reuptake inhibitor (SSRI).

DESIGN

One-year costs and frequencies of all medical services, and of services coded for depression, were compared between patients who received venlafaxine and TCA therapy as second-line therapy using bivariate and multivariate statistical analyses.

SETTING

Data were obtained from 9 individual health plans with more than 1.1 million covered lives affiliated with a national managed-care organisation.

PATIENTS AND PARTICIPANTS

Health plan members were included if they had a diagnosis of depression between July 1993 and February 1997. They also had to have at least 2 months of prescriptions for SSRI therapy followed by at least 2 months of venlafaxine or TCA therapy, and continuous enrollment in the plan from at least 6 months prior to 12 months following initiation of venlafaxine or TCA therapy. 188 patients who received venlafaxine and 172 patients who received TCAs met the inclusion criteria.

MAIN OUTCOME MEASURES AND RESULTS

Patients who received TCAs were slightly but significantly older (43 vs 40 years) than venlafaxine recipients and, during 6 months prior to initiating therapy, had significantly higher mean costs coded for depression ($US451 vs $US311) and costs not coded for depression ($US4500 vs $US2090). Psychiatrists prescribed a significantly higher proportion of venlafaxine than TCA prescriptions (46.3 vs 25.0%). Prior to adjusting for confounding characteristics, during 12 months following initiation of therapy, mean depression-coded costs were significantly higher for venlafaxine than TCA recipients ($US1948 vs $US1396) and mean costs not coded for depression were significantly lower ($US4595 vs $US6677). Overall costs were not significantly different ($US6543 for venlafaxine vs $US8073 for TCA). Significant cost differences were observed with primary care physicians as initial prescribers of second-line therapy but not with psychiatrists. However, costs between the 2 groups were similar after adjusting for confounding variables, including prior 6-month costs and initial prescriber of second-line therapy.

CONCLUSIONS

Payer costs are similar among patients receiving venlafaxine and TCA therapy following SSRI therapy. Higher costs of venlafaxine pharmacotherapy relative to TCA therapy may be offset by lower costs of other medical services. Differences in prescribing patterns and costs between primary care physicians and psychiatrists warrant further investigation.

Information needs for medication coverage decisions in a state Medicaid program

BACKGROUND

Health plans commonly face the conflicting demands of trying to provide access to novel technologies, including new classes of medications, while trying to contain costs. These demands are particularly acute for California's Medicaid program, known as Medi-Cal, which is responsible for delivery of medical care to an unusually large population of mentally ill individuals in the context of a culturally diverse environment. To meet the challenge, Medi-Cal has instituted a formal process for technology assessment of new and existing pharmaceutical products known as the Therapeutic Class Review (TCR).

OBJECTIVE

The purpose of this paper is to describe the information produced for Medi-Cal in the TCR process for antidepressant medications and the individual petition review of antipsychotic medications, and to synthesize our experience in a series of policy recommendations designed to improve the quality of coverage decisions.

OUTCOME

A collaborative process between Medi-Cal and Lilly resulted in a substantive body of new evidence regarding the needs of Medi-Cal recipients, the quality of current treatment, and prospects regarding the cost-effectiveness of introducing newer treatments.

CONCLUSION

Medi-Cal has a formal process for evaluating new medicines. This process allows researchers to understand the needs of those who make coverage decisions. We recommend increasing routine epidemiologic surveillance, including service use, and clinical trials that include aspects of usual medical care early in the drug development process.

Selective serotonin reuptake inhibitors have broadened the utilisation of antidepressant treatment in accordance with recommendations. Findings from a Swedish prescription database

BACKGROUND

With the advent of the selective serotonin reuptake inhibitors (SSRIs), the use of antidepressants has increased drastically in Sweden. The use of tricyclic antidepressants (TCAs) has, however, decreased.

METHODS

We surveyed a prescription database in the Swedish county of Jämtland and compared prescription patterns for patients prescribed SSRIs with those prescribed TCAs.

RESULTS

The incidence of treatments of antidepressants increased from 0.76% to 1.33% during the period 1991-1996. There were no significant differences between SSRIs and TCAs with regard to patients having only one prescription dispensed within three months from the index prescription, or patients who switched class of antidepressant. Only a minority of the treatments were continued for at least six months, but significantly more SSRI than TCA treatments (42% and 27%). A second treatment period suggesting recurrence was three-times more common in the TCA group than in the SSRI group.

CONCLUSION

Provided that the increased use of SSRIs is mainly for depression, these drugs appear, despite a lower efficacy in severe depression, to have enabled a broader utilisation of antidepressants with regard to incidence, dosage and duration, in accordance with recommendations. Further analyses of this phenomenon relative to diagnostic criteria and outcome measures are required.

Antidepressant agents: from tricyclics to serotonin uptake inhibitors

BACKGROUND

The number of antidepressant drugs available in the market has grown rapidly in the last few years. The present paper underlines some of the pre-clinical and clinical problems that call close attention from the regulatory authorities when approving new drugs.

METHODS

We present here a review of the literature.

RESULTS

A wide heterogeneity in the action of the various antidepressants precludes any single theory about the pathogenesis and therapy of depression. Antidepressant activity, in fact, may be achieved by acting on a number of different monoaminergic mechanisms. The variety in the neurochemical effects of antidepressants is not reflected in clinical trials, which tend to stereotypy. In many cases clinical trials aim at demonstrating equivalence rather than differences in efficacy. Regulatory authorities should, therefore, pay attention in accepting the equivalence of effects of a new drug in relation to a reference one: most clinical trials of new antidepressant drugs do not have the power to detect clinically relevant differences.

CONCLUSIONS

Unconventional new pre-clinical tests are needed to generate antidepressants with a different mechanism of action. Clinical studies are needed to promote objective comparative evaluation of the cost, benefits and toxic effects of new antidepressants.

Economic outcomes with antidepressant pharmacotherapy: a retrospective intent-to-treat analysis

Herein we describe a retrospective intent-to-treat evaluation designed to compare the natural course of antidepressant utilization and direct health service expenditures for the treatment of a single episode of major depression among patients enrolled in a multistate network-model health maintenance organization and initially prescribed either a tricyclic antidepressant (amitriptyline or nortriptyline) or the serotonin selective reuptake inhibitor (SSRI) fluoxetine. Patient-level paid-claims data for the period July 1, 1988, through December 31, 1991, were abstracted. During the above time frame, fluoxetine was the only SSRI available in the United States. Patients prescribed amitriptyline were more than three times as likely to require a change in antidepressant pharmacotherapy (OR = 3.27, 95% CI = 2.31 to 5.49), while patients prescribed nortriptyline were nearly four times more likely to change medication (OR = 3.82, 95% CI = 2.74 to 6.83) relative to patients initially prescribed fluoxetine. Consistent with our intent-to-treat design, all accrued health service expenditures were assigned to the pharmacotherapeutic option initially prescribed. Multivariate analyses revealed that initiation of antidepressant pharmacotherapy with amitriptyline resulted in a 25.7% increase in per capita depression-related health service expenditures per year, while initiation of antidepressant pharmacotherapy with nortriptyline resulted in a 28.1% increase in per capita depression-related health service expenditures per year relative to patients initially prescribed fluoxetine. A financial break-even point was achieved at the conclusion of Month 5, at which time all three intent-to-treat cohorts had comparable health service expenditures in total. From a financial perspective, results stemming from this inquiry suggest that the initiation of antidepressant pharmacotherapy with an SSRI is warranted.

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.