Cost-effectiveness of antidepressant medications

BACKGROUND: Antidepressant medications have been shown to effectively relieve symptoms, improve interpersonal and occupational functioning and reduce disability from coexisting medical conditions. Although the newer selective serotonin reuptake inhibitors (SSRIs) have improved tolerability, are easier to take and are associated with longer lengths of therapy when compared with the tricyclic antidepressants (TCAs), the relative cost-effectiveness of alternative antidepressants remains unclear. AIMS OF THE STUDY: This study seeks to determine (i) the probability that relapse or recurrence of depression can be prevented by appropriate antidepressant choice, (ii) the cost associated with relapse or recurrence of depression and (iii) the relative cost-effectiveness of alternative antidepressants. METHODS: We use a quasi-experimental design to compare claims from a state Medicaid plan for TCA and SSRIs users. RESULTS: Premature discontinuation of antidepressant medication is the strongest predictor of relapse and recurrence. Antidepressant choice was not an independent predictor of relapse or recurrence. The effect of relapse and recurrence on expenditures is complex, with a non-significant trend toward lower expenditures for those who had longer periods between episodes of depression two years after initiation of treatment for the first episode. We were unable to replicate prior research results regarding the impact of SSRIs on duration of therapy in this Medicaid plan. CONCLUSIONS: Premature discontinuation of antidepressant treatment is associated with a high probability of relapse and recurrence. Health care expenditures are not altered by preventing relapse and recurrence. We suggest that antidepressant medications associated with reduced probability of premature discontinuation should be considered cost-effective. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: There are very few variables which health care providers can use to improve the outcomes and associated economic consequences of depression. Among these factors, treatment choice and adherence to the prescribed treatment are likely candidates. In this paper, we suggest that adherence to antidepressant medication results in substantial improvement in the time to relapse or recurrence of depression. Choice of an SSRI may thus improve treatment outcome by lengthening remission. In addition, this choice is not associated with higher costs. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Depressive illnesses are associated with high rates of health service use and functional impairment. Thus, the societal burden is quite high. This paper furthers the debate regarding the relative cost-effectiveness of antidepressant medications, and our findings suggest several ways that policy makers can improve the care of depressed individuals at little additional cost. Specifically our findings highlight the importance of adherence to current recommendations regarding the length of antidepressant treatment and suggest several methods for improving this important outcome. IMPLICATIONS FOR FURTHER RESEARCH: The relative cost-effectiveness of alternative antidepressant medications continues to be an important and unsolved issue. We suggest the need for future research in this area using a variety of research designs appropriate to the question. The quasi-experimental approach outlined here seems promising in this regard.     

Competing demands from physical problems: effect on initiating and completing depression care over 6 months

OBJECTIVE AND DESIGN: To evaluate a cohort of patients with major depression to examine the effect of competing demands on depression care during multiple visits over 6 months. PARTICIPANTS AND SETTING: Ninety-two patients with 5 or more symptoms of depression and no recent depression treatment were evaluated by 12 primary care physicians in 6 practices in the usual-care arm of an effectiveness trial of the Agency for Health Care Policy and Research Depression Guidelines. MAIN OUTCOME MEASURE: Treatment was considered to be initiated if the patient reported starting a guideline-concordant antidepressant medication or making a visit for specialty counseling. Treatment completion was defined as either a 3-month course of guideline-concordant antidepressant use or completion of 8 or more specialty counseling visits. RESULTS: Among the 92 patients reporting no recent treatment at study enrollment, 57% reported starting and 17% reported completing a course of guideline-concordant antidepressant medication and or specialty counseling at the 6-month interview. The severity of physical problems among patients with high enthusiasm for depression treatment decreased the odds that patients would initiate depression therapy. Severity of physical problems had no observable effect on completing depression therapy in the group of patients who initiated treatment. CONCLUSIONS: Physical problems compete with depression for attention over multiple visits in untreated patients who are enthusiastic about getting care for their emotional problems. Interventions are needed for this high-risk group, because depression treatment could potentially enhance patients' treatment of their physical problems. Arch Fam Med. 2000;9:1059-1064     

Diabetes and depression care among medicaid beneficiaries

This study evaluates the relationship between diabetes mellitus and depression care among non-elderly Medicaid beneficiaries, using claims data from the 1995 State Medicaid Research Files for Alabama, Georgia, New Jersey, and Wisconsin. Presence of comorbid diabetes was found to be significantly associated with a higher rate of depression diagnosis. Among those who were diagnosed as depressed, treatment of comorbid diabetes was associated with a higher rate of antidepressant treatment than among depression-diagnosed patients who did not also have diabetes. However, among patients with diabetes and depression, a quarter received only tricyclic antidepressants. Controlling for other characteristics, African Americans diagnosed with depression were less likely to receive antidepressant treatment and, if they did receive such treatment, more likely to receive the older tricyclic drugs. These findings raise concern for glycemic control among patients with diabetes and depression treated with tricyclic antidepressants in a low-income Medicaid population. Among depressed Medicaid beneficiaries with diabetes, there are racial differences with regard to quality of mental health care in the presence of diabetes.     

Antidepressant Use During Breastfeeding

BACKGROUND: The treatment of breastfeeding mothers with depression raises several dilemmas, including the possible risk of drug exposure through breast milk for the infant. This article provides background information and presents practical advice and recommendations for the clinician dealing with the treatment of depression and related disorders in the postpartum period. METHODS: An electronic search for relevant articles was performed. As the use of tricyclic antidepressants has considerably decreased during the last decade and no new information on breastfeeding has emerged for the tricyclics in this period, this review exclusively focuses on the newer, non-tricyclic compounds. RESULTS: Most newer antidepressants produce very low or undetectable plasma concentrations in nursing infants. The highest infant plasma levels have been reported for fluoxetine, citalopram and venlafaxine. Suspected adverse effects have been reported in a few infants, particularly for fluoxetine and citalopram. CONCLUSIONS: Infant exposure of antidepressants through breast milk is generally low to very low. We consider that when antidepressant treatment is indicated in women with postpartum depression, they should not be advised to discontinue breastfeeding. Paroxetine and sertraline are most likely suitable first-line agents. Although some concern has been expressed for fluoxetine, citalopram and venlafaxine, we nevertheless consider that if the mother has been treated with one of these drugs during pregnancy, breast-feeding could also be allowed during continued treatment with these drugs in the postpartum period. However, an individual risk-benefit assessment should always be performed.     

Patient beliefs predict response to paroxetine among primary care patients with dysthymia and minor depression

BACKGROUND: Dysthymia and minor depression are common problems in primary care, but it is not known how patient health beliefs shape response to antidepressant treatment of these less severe forms of depression. METHODS: Three hundred thirty-three primary care patients with dysthymia or minor depression received at least 4 weeks of paroxetine or placebo in a multicenter, randomized controlled 11-week trial. Patient health beliefs and other characteristics were examined as predictors of treatment adherence and depression remission. RESULTS: Patient beliefs were not predictive of adherence to paroxetine or placebo. Patients with less endorsement of biological beliefs about their condition (odds ratio [OR] = 3.40), higher perceived general health (OR = 3.38), meeting criteria for dysthymia (OR = 2.37), and age younger than 60 years (OR = 2.68) were more likely to achieve remission on paroxetine. Patient beliefs did not predict remission on placebo. Those with lower severity of depression symptoms at baseline (OR = 2.70) and women (OR = 2.18) were most likely to achieve remission on placebo. CONCLUSIONS: Our results suggest that patients with dysthymia or minor depression are more likely to respond to antidepressant medication if they do not see their depression as a biological illness and see themselves as generally healthy. It is clearly not necessary for patients to believe that their dysthymia or minor depression is biological to respond to antidepressant medication.     

Health Care Expenditures for Urban and Rural Veterans in Veterans Health Administration Care

Objective. To compare Veterans Health Administration (VA) patients, non-VA-using veterans, and nonveterans, separated by urban/rural residence and age group, on their use of major categories of medical care and payment sources.
Data Source. Expenditures for health care–using men in Medical Expenditure Panel Surveys from 1996 through 2004.
Study Design. Retrospective, cross-sectional analysis.
Data Collection/Extraction Methods. Controlling for demographics, health status, and insurance, we compared groups on population-weighted expenditures for inpatient, hospital-based outpatient, office-based, pharmacy, and other care, by major payers (self/family, private insurance, Medicare, other sources, and VA).
Results. VA users received most of their health care outside of the VA system, paid through private insurance or Medicare; self-payments were substantial. VA users under 65 reported worse health if they were rural residents but also lower expenditures overall and less care through private insurance.
Conclusions. VA health care users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.     

The influence of health care utilization on the association between hormonal contraception initiation and subsequent depression diagnosis and antidepressant use

ObjectiveAssess the influence of healthcare utilization on previously reported associations between contraception initiation, diagnosis of depression, and dispensing of antidepressant medications.Study designRetrospective cohort analysis of insurance records from 272,693 women ages 12–34 years old enrolled in the United States Military Healthcare System in September 2014 and followed for 12 months. We compared outcomes of women who initiated hormonal contraception with all women eligible for care and then with women who accessed care during the study month using Kaplan-Meier and Cox proportional hazards analyses.ResultsWomen age 12–34 who initiated hormonal contraception experienced a higher risk of depression diagnosis and antidepressant use when compared to all enrolled women but not when compared to women who accessed care. Among those who accessed care, some progestins (i.e., levonorgestrel, Hazard Ratio (HR) = 1.46, and norelgestromin, HR = 1.93) were associated with an increased rate of depression diagnosis but not antidepressant use; norethindrone (HR = 0.21) was associated with a decreased rate of depression diagnosis.ConclusionWhen compared to women utilizing their health insurance, associations between initiating hormonal contraception and depression diagnosis and antidepressant use decreased or disappeared. This suggests that healthcare utilization may have confounded previous reports of an association between hormonal contraception use and depression and antidepressant use.     

Antidepressant Treatment Patterns and Success Rates in a Managed Care Organization

Objective

The purpose of this study was to evaluate the treatment patterns and success rates with antidepressants utilized by patients in a managed care organization (MCO).

Methods

Data were extrapolated from a claims database from an MCO with 225 000 members. Treatment patterns were determined by creating episodes of care for each patient. Successful treatment was defined as a therapeutic dose for at least 180 days of continuous therapy. Success rates were stratified by the type of antidepressant used. Depression-related and total healthcare costs were analyzed in relation to whether a patient’s treatment was successful.

Results

A minority of patients received continuous therapeutic doses for 180 days for their first treatment episode (26.5%) or all treatment episodes of depression (32.9%). Monotherapy was the most common treatment pattern. Treatment with a selective serotonin reuptake inhibitor (SSRI) was associated with a significantly higher success rate than treatment with a tricyclic antidepressant (TCA), in patients with depression (36.6 vs 13.3%). In patients with depression who were receiving SSRIs, the success rates were 37.2% with fluoxetine, 36.2% with paroxetine, and 36.1% with sertraline; there were no significant differences in the success rates among the SSRIs. Patients completing a successful treatment episode were associated with higher pharmacy, depression-related, and total healthcare costs.

Conclusions

Only a minority of patients with depression attained a satisfactory treatment episode with their antidepressant therapy. SSRI therapy was associated with a significantly higher success rate than TCAs. Although monotherapy regimens were the most commonly used treatment strategy, the multivariate analysis reveals that multiple regimen changes (defined as complex in this analysis) may be required to achieve successful treatment. Physicians and MCOs need to monitor patients and be open to necessary regimen changes. Physicians and MCOs must also work together to develop improved strategies to monitor and detect patients with depression who do not comply with their antidepressant regimen.

     

Clinical and therapeutic particularities of depression in the elderly

Depression in older people slightly differs from younger subjects adults. Generally, typical depressive symptoms are overlooked by other symptoms. The most frequent ones are excessive preoccupation with health and complaints about physical symptoms. Anxiety is a common accompaniment of depression in later life. Poor subjective memory or dementia-like and psychotic symptoms are also common in depression in the elderly. The exogenous depression, the most common forms of depression in elderly people, has a little response to antidepressants. The endogenous depression is associated with high risk of suicide. Depression in older people often coexists with physical disorders. The most frequently encountered is Parkinson's disease. Depression could also be one of the side effect of the use of drugs for physical illnesses. The Tricyclic antidepressants (TCAs) are generally too toxic for elderly people and should not be considered as drugs of first choice. Currently, the drugs of choice are the serotonin-selective reuptake inhibitors (SSRIs). They have an antidepressant effect similar to that of (TCAs), but they are less toxic. The antidepressant treatment in the elderly is usually initiated at a low starting dose, ideally no more than half the usually recommended for the adults. For psychotic depression a combination of an antidepressant used in conjunction with antipsychotic drug is more effective than an antidepressant administered alone. The treatment should be continued for six months at least in order to reduce the risk of relapse. Moreover, long-term treatment is recommended because of the high risk of recurrence.