Abstract
ObjectiveTo determine effectiveness and cost-effectiveness over a one-year time horizon of pharmacological first line treatment in primary care for patients with moderate to severe depression.DesignA multiple treatment comparison meta-analysis was employed to determine the relative efficacy in terms of remission of 10 antidepressants (citalopram, duloxetine escitalopram, fluoxetine, fluvoxamine mirtazapine, paroxetine, reboxetine, sertraline and venlafaxine). The estimated remission rates were then applied in a decision-analytic model in order to estimate costs and quality of life with different treatments at one year.Data SourcesMeta-analyses of remission rates from randomised controlled trials, and cost and quality-of-life data from published sources.ResultsThe most favourable pharmacological treatment in terms of remission was escitalopram with an 8- to 12-week probability of remission of 0.47. Despite a high acquisition cost, this clinical effectiveness translated into escitalopram being both more effective and having a lower total cost than all other comparators from a societal perspective. From a healthcare perspective, the cost per QALY of escitalopram was €3732 compared with venlafaxine.ConclusionOf the investigated antidepressants, escitalopram has the highest probability of remission and is the most effective and cost-effective pharmacological treatment in a primary care setting, when evaluated over a one year time-horizon. Small differences in remission rates may be important when assessing costs and cost-effectiveness of antidepressants.
Highlights
Current guidelines for the pharmacological treatment of moderate to severe major depressive disorder uniformly recommend generic formulations of selective serotonin reuptake inhibitors (SSRI) as first line treatment [1,2,3,4].systematic reviews have found evidence that some of the newer additions to the therapeutic arsenal– in particular the SSRI escitalopram and the serotonin nor-adrenaline reuptake inhibitor (SNRI) venlafaxine– may have a somewhat better efficacy than other second-generation antidepressants [2,5,6]
Of the investigated antidepressants, escitalopram has the highest probability of remission and is the most effective and cost-effective pharmacological treatment in a primary care setting, when evaluated over a one year timehorizon
Interventions and Outcomes Costs and health outcomes of ten antidepressants considered relevant for first line treatment of patients with a diagnosis of major depressive disorder in primary care were compared in our decision analytic model: citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine mirtazapine, paroxetine, reboxetine, sertraline and venlafaxine
Summary
Current guidelines for the pharmacological treatment of moderate to severe major depressive disorder uniformly recommend generic formulations of selective serotonin reuptake inhibitors (SSRI) as first line treatment [1,2,3,4].systematic reviews have found evidence that some of the newer additions to the therapeutic arsenal– in particular the SSRI escitalopram and the serotonin nor-adrenaline reuptake inhibitor (SNRI) venlafaxine– may have a somewhat better efficacy than other second-generation antidepressants [2,5,6]. Current guidelines for the pharmacological treatment of moderate to severe major depressive disorder uniformly recommend generic formulations of selective serotonin reuptake inhibitors (SSRI) as first line treatment [1,2,3,4]. As the newer treatment options are generally more expensive than drugs for which generic formulations are available, potential improvement in efficacy has to be balanced against treatment costs. This is important as untreated or poorly treated depression is costly for societies around the world [7], suggesting that relatively small differences in efficacy may offset a higher acquisition cost. When jointly considering response and acceptability, Cipriani et al found escitalopram and sertraline to have the best profile of both efficacy and acceptability leading to the tentative conclusion that the generi-
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