Pharmacotherapeutic strategies for patients treated for depression in UK primary care: a database analysis

OBJECTIVE

To investigate long-term patterns of antidepressant treatment in patients in primary care in the UK, and to assess their healthcare resource use and disease outcomes.

RESEARCH DESIGN AND METHODS

A retrospective longitudinal cohort study was conducted using the Clinical Practice Research Datalink. The study population comprised patients aged ≥18 years with depression receiving a prescription for antidepressant monotherapy between 1 January 2006 and 31 December 2011 with no antidepressants within the preceding 6 months. Recovery was defined by timing of antidepressant prescriptions (≥6 months without treatment). Treatment lines and strategies (switching, combining, augmenting and resuming medication) were analyzed. Healthcare resource use for the different treatment strategies and periods of no therapy was assessed.

RESULTS

Data from 123,662 patients (287,564 treatment lines) were analyzed. Switching and resumption of treatment were more frequent than other strategies. Recovery was highest with first-line monotherapy (45% of patients), while as a second-line strategy switching was more successful (43%) than combination or augmentation. In subsequent lines of treatment, switching was associated with successively lower rates of recovery (31% in the third line and 24% from the fourth line onwards). Similar rates were observed for resumption. Healthcare resource use was greater during antidepressant use than treatment-free periods. Augmentation was associated with the highest proportions of patients with a psychiatrist referral, psychologist referral and psychiatric hospitalization.

CONCLUSIONS

This study provides extensive real-world information on the prescribing patterns and treatment outcomes for a large cohort of patients treated for depression with antidepressants in primary care. Switching is more frequently used than augmentation or combination treatment, with decreasing effectiveness across successive lines. Key limitations of the study were: (i) risk of selection bias due to the use of inclusion criteria based on depression diagnoses recorded by the practitioner; and (ii) reliance on prescribing patterns as proxies for clinical outcomes, such as recovery.

The role of socio-economic data in food needs assessment and monitoring

This paper reviews six case studies examined as part of a project to review targetting methodologies employed by non-government organisations in Africa during the 1984-6 food crisis. Most agencies have not yet fully evaluated the role of data in informing policy decisions during their respective emergency programmes. The case studies presented reflect a wide variety of approaches to targetting emergency food aid that are based largely on the use of 'socio-economic' data. The recent emergency relief operations in Africa seem to indicate a change in relief agencies' approaches to the assessment and monitoring of needs of the affected populations. Earlier dependance on nutritional data has given way to an increasing reliance on the use of socio-economic indicators. There was a wide variation in the case studies of the type of indicators collected and utilised in needs assessment and monitoring. There were those who relied almost exclusively on nutritional data to target resources during the 1984-86 African crisis, and others whose experiences during that period lead them to attach more weight to socio-economic data. Other agencies appear to have recognised the problems of relying solely on nutritional data to target food aid during their 1984-86 emergency programmes, and thus more or less abandoned classical anthropometric surveys in their needs assessment and monitoring methodologies during this period. Thus nutritional data has a less significant role in the decision making process than previously had been the case.

The African food crisis of 1982-1986*

The crisis cannot be attributed to any one cause, but rather it was the product of a number of interacting factors whose precise combination varied between countries. Drought, internal political and economic factors and an unfavourable external economic environment were significant contributory factors. Civil war and externally financed insurgency were primarily responsible for propelling a food crisis into a famine in four out of the six worst affected countries. Within the literature, there is a tendency for writers to emphasize the relative contribution of factors within their own disciplines. So far the literature on the responses, both within country and internationally, is comprised of eye witness accounts by journalists and evaluations by aid agencies of their performance. The international response by governments and the public was massive and unprecedented, but the response by governments, indigenous NGO's and the public within affected countries is often overlooked by the journalistic literature. Generalizations about "the African food crisis" have obscured the considerable diversity amongst countries. This is well illustrated by the experiences of Ethiopia, Kenya and Botswana. This diversity indicates the biased perspectives that arise from focussing on the extreme famines, as in Ethiopia. Research priorities should include studies of systems that coped during the crisis, historical analysis of the crisis, the way early warning information is processed within bureaucratic institutions, environmental degradation and fully integrated analysis of food production and consumption systems.