Treatment-resistant depression: managed care considerations.

Abstract

Treatment-resistant depression (TRD) presents a unique challenge in managed care, requiring review of both the clinical and economic components of care. To review the TRD disease state as well as data supporting the various therapeutic options available for the treatment of persistent depression in managed care. While there is no consensus on the definition of TRD, persistent disease can generally be defined as depression that fails to respond to adequate treatment. When initial treatment is not effective or tolerable after 6 to 8 weeks of therapy, the American Psychiatric Association (APA) treatment guidelines recommend dose titration, augmentation, or switching. In the case of a therapy switch, the body of evidence suggests that selection of an agent with a different mechanism of action than the initial agent may be the most effective treatment. Furthermore, when patients maintain continuous therapy for the recommended treatment duration, outcomes are improved compared with patients who discontinue therapy early. As a result, the most effective treatment strategies promote improved patient compliance as well as the use of agents associated with a reduced incidence of premature discontinuation and therapy change early in the treatment program. While data supporting these clinically effective components of therapy exist, few data are available demonstrating the most cost-effective therapeutic options for TRD. This analysis suggests that managed care providers could benefit from a model that they can customize to evaluate the overall costeffectiveness of different strategies in the management of depression.