Economic implications of treatment-resistant depression among employees

Approaches to understanding and addressing treatment-resistant depression: a scoping review

Treatment-resistant depression is associated with significant disability and, due to its high prevalence, results in substantive economic and societal burden at a population level. The objective of this study is to synthesize extant literature on approaches currently being applied to understand and address this condition. It is hoped that the findings can be used to inform practitioners and guide future research. A scoping review of the scientific literature was conducted with findings categorized and charted by underlying research paradigm. Currently, the vast majority of research stems from a biological paradigm (81%). Research on treatment-resistant depression would benefit from a broadened field of study. Given that multiple etiological mechanisms likely contribute to treatment-resistant depression and current efforts at prevention and treatment have substantial room for improvement, an expanded research agenda could more effectively address this significant public health issue.

Treatment-resistant depression: therapeutic trends, challenges, and future directions

BACKGROUND

Patients with major depression respond to antidepressant treatment, but 10%-30% of them do not improve or show a partial response coupled with functional impairment, poor quality of life, suicide ideation and attempts, self-injurious behavior, and a high relapse rate. The aim of this paper is to review the therapeutic options for treating resistant major depressive disorder, as well as evaluating further therapeutic options.

METHODS

In addition to Google Scholar and Quertle searches, a PubMed search using key words was conducted, and relevant articles published in English peer-reviewed journals (1990-2011) were retrieved. Only those papers that directly addressed treatment options for treatment-resistant depression were retained for extensive review.

RESULTS

Treatment-resistant depression, a complex clinical problem caused by multiple risk factors, is targeted by integrated therapeutic strategies, which include optimization of medications, a combination of antidepressants, switching of antidepressants, and augmentation with non-antidepressants, psychosocial and cultural therapies, and somatic therapies including electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, deep brain stimulation, transcranial direct current stimulation, and vagus nerve stimulation. As a corollary, more than a third of patients with treatment-resistant depression tend to achieve remission and the rest continue to suffer from residual symptoms. The latter group of patients needs further study to identify the most effective therapeutic modalities. Newer biomarker-based antidepressants and other drugs, together with non-drug strategies, are on the horizon to address further the multiple complex issues of treatment-resistant depression.

CONCLUSION

Treatment-resistant depression continues to challenge mental health care providers, and further relevant research involving newer drugs is warranted to improve the quality of life of patients with the disorder.

Resource utilization and costs associated with insomnia treatment in patients with major depressive disorder

OBJECTIVE

To estimate resource utilization and costs associated with insomnia treatment among newly treated patients with major depressive disorder (MDD).

METHOD

Data from the MarketScan(®) Research Databases (Commercial Claims and Encounters, Medicare Supplemental and Coordination of Benefits, and Health and Productivity Management) were analyzed. Patients aged ≥ 18 years with a first prescription claim for an antidepressant between January 1, 2006, and December 31, 2007 (index date), were included in the analysis if they had ≥ 1 MDD diagnosis (ICD-9-CM criteria) in the 12 months prior to the claim and 24 months of continuous insurance coverage. Patients were categorized into 2 groups on the basis of the presence or absence of insomnia medication during the 12 months following the index date. Multivariate analyses were conducted to compare all-cause and MDD-related hospitalization and emergency room (ER) visits and costs in the year following the index date between patients with and without insomnia medication. Covariates for adjustment included age, gender, region, health plan type, baseline comorbidities, and health care utilization.

RESULTS

The total sample size was 87,461 newly treated MDD patients with a mean (SD) age of 43.5 (15.1) years; 67% were women. Among newly treated patients, 10,339 (11.8%) took insomnia medication. Patients taking insomnia medication were significantly more likely to be hospitalized (OR = 1.84, 95% CI = 1.73-1.96 for all cause; OR = 1.50, 95% CI = 1.43-1.57 for MDD related; P < .0001) and to have ER visits (OR = 4.25, 95% CI = 3.65-4.95 for all cause; OR = 2.51, 95% CI = 2.24-2.81 for MDD related; P < .0001) than the patients not taking insomnia medication. Adjusted all-cause health care costs were $3,918 (95% CI = $3,599-$4,290) higher and MDD-related health care costs were $537 (95% CI = $492-$586) higher in the insomnia medication cohort compared with controls in the 12-months following the index date. Patients taking insomnia medication had $1,162 more indirect costs for short-term disability compared to the control group (95% CI = $746-$1,684).

CONCLUSIONS

The use of insomnia medications in newly treated patients with MDD appears to be associated with increased health care resource utilization and higher total and depression-related direct and indirect medical costs.

Algorithm-guided treatment of depression reduces treatment costs--results from the randomized controlled German Algorithm Project (GAPII)

BACKGROUND

The German Algorithm Project, Phase 2 (GAP2) revealed that a standardized stepwise treatment regimen (SSTR) results in better treatment outcomes than treatment as usual (TAU) in depressed inpatients. The objective of this study was a health economic evaluation of SSTR based on a cost effectiveness analysis (CEA).

METHODS

GAP2 was a randomized controlled study with 148 patients. In an intention to treat (ITT) analysis direct treatment costs for study duration (SD) and total time in hospital (TTH; enrolment to discharge) were calculated based on daily hospital charges followed by a CEA to calculate cost expenditure per remitted patient.

RESULTS

Treatment costs in SSTR compared to TAU were significantly lower for SD (SSTR: 10 830 € ± 8 632 €, TAU: 15 202 € ± 12 483 €; p = 0.026) and did not differ significantly for TTH (SSTR: 21 561 € ± 16 162 €; TAU: 18 248 € ± 13 454; p = 0.208). CEA revealed that the costs per remission in SSTR were significantly lower for SD (SSTR: 20 035 € ± 15 970 €; SSTR: 38 793 € ± 31 853 €; p<0.0001) and TTH (SSTR: 31 285 € ± 23 451 €; TAU: 38 581 € ± 28 449 €, p = 0.041).

LIMITATIONS

Indirect costs were not assessed. Different dropout rates in TAU and SSTR complicated interpretation of data.

CONCLUSION

An SSTR-based algorithm results in a superior cost effectiveness at no significant extra costs. Implementation of treatment algorithms in inpatient-care may help reduce treatment costs.

Intent-to-treat analysis of health care expenditures of patients treated with atypical antipsychotics as adjunctive therapy in depression

OBJECTIVE

To compare health care utilization and expenditures in patients with depression whose initial antidepressant (AD) treatment was augmented with a second-generation antipsychotic.

METHODS

Claims data from January 1, 2001, through June 30, 2009, were used to select patients aged 18 to 64 years with depression treated with ADs augmented with aripiprazole, olanzapine, or quetiapine. Patients were required to have 6 months of continuous eligibility before the first AD prescription and 6 months after the second-generation antipsychotic augmentation (index) date. Utilization and expenditures were assessed for 6 months after the index date. Multivariate regression was used to estimate adjusted expenditures and risks for hospitalizations and emergency department visits.

RESULTS

A total of 483 patients treated with aripiprazole, 978 with olanzapine, and 2471 with quetiapine were selected. Mean adjusted expenditures for aripiprazole were significantly lower than those for olanzapine for each service category (all-cause, all-cause medical care, mental health-related, and mental health-related medical care) and were significantly lower than those for quetiapine for each category with the exception of mental health-related. The adjusted risks for hospitalization and emergency department visits were significantly higher for quetiapine than for aripiprazole.

CONCLUSIONS

Compared with patients treated with ADs and aripiprazole, those treated with ADs and olanzapine or quetiapine had greater utilization and higher expenditures.

Update in the methodology of the chronic stress paradigm: internal control matters

To date, the reliability of induction of a depressive-like state using chronic stress models is confronted by many methodological limitations. We believe that the modifications to the stress paradigm in mice proposed herein allow some of these limitations to be overcome. Here, we discuss a variant of the standard stress paradigm, which results in anhedonia. This anhedonic state was defined by a decrease in sucrose preference that was not exhibited by all animals. As such, we propose the use of non-anhedonic, stressed mice as an internal control in experimental mouse models of depression. The application of an internal control for the effects of stress, along with optimized behavioural testing, can enable the analysis of biological correlates of stress-induced anhedonia versus the consequences of stress alone in a chronic-stress depression model. This is illustrated, for instance, by distinct physiological and molecular profiles in anhedonic and non-anhedonic groups subjected to stress. These results argue for the use of a subgroup of individuals who are negative for the induction of a depressive phenotype during experimental paradigms of depression as an internal control, for more refined modeling of this disorder in animals.

Effects of repetitive transcranial magnetic stimulation of the dorsolateral prefrontal cortex on the attentional processing of emotional information in major depression: a pilot study

Repetitive transcranial magnetic stimulation (rTMS) is as a promising therapeutic tool for major depressive disorder. However, the degree of clinical improvement following rTMS treatment still remains questionable. This pilot study aimed at investigating potential working mechanisms of rTMS by examining the effects on attentional processing towards negative information, a proposed underlying cognitive vulnerability factor for depression. The antidepressant effect of high-frequency (10 Hz) rTMS over the left dorsolateral prefrontal cortex and possible effects on the inhibitory processing of emotional information was assessed in a sample of 14 depressed patients immediately after the first stimulation session and at the end of a 2-week treatment period. One session of rTMS caused neither significant self-reported mood changes, nor improvements in inhibitory control towards negative information. After a 10-day treatment period, nine out of our 14 patients demonstrated significant mood improvements, as indexed by a reduction of more than 50% on the Hamilton depression rating scale. Responders also demonstrated significant improvements in the inhibitory processing of negative information. This study contributed to the existing evidence of the antidepressant effect of rTMS in the treatment of depression and additionally was able to demonstrate improvements in underlying deficiencies in inhibitory processes towards negative information.

The economic impact of depression: resistance or severity?

Treatment-Resistant Depression (TRD) affects 60 to 70% of patients with Major Depressive Disorder (MDD). The economic impact of depression in general, and of TRD specifically, was found to be relatively high. As the course of depression can be defined both by the severity of the disease and by the resistance to treatment, the question of the unique contribution of MDD severity vs. resistance to the economic burden of depression is being raised. One hundred and seven unipolar MDD patients, all treated for at least 4weeks, were enrolled in the study. Patients were assessed for their current MDD severity using the Hamilton Depression Rating Scale (HDRS) and past treatments, and for medical-related costs (number of blood and imaging tests, visits paid to physicians, psychiatric hospitalizations) and incapacity-related costs (number of working days lost) during the last episode. TRD and non-TRD patients were, respectively, 39.3% and 60.7% of the patients recruited for the study. TRD patients had more severe depression, and higher costs for imaging tests, physician visits, psychiatric hospitalizations, and number of working days lost. In addition, higher MDD severity was found to be associated with higher costs. Finally, when controlling for the shared variance of TRD and MDD severity, by using residual scores, TRD was associated with higher costs, but MDD severity was no longer related to costs. While both resistance and severity are associated with higher direct and indirect costs, our findings suggest that TRD may be the main factor in determining the economic burden of depression.

Direct and indirect costs of employees with treatment-resistant and non-treatment-resistant major depressive disorder

OBJECTIVE

Treatment-resistant depression (TRD) imposes substantial cost from the perspective of employers. The objective of this study was to assess direct healthcare costs and indirect (disability and medical-related absenteeism) costs associated with TRD compared with non-treatment-resistant major depressive disorder (MDD).

METHODS

Employees with one or more inpatient, or two or more outpatient/other MDD diagnoses (ICD-9-CM: 296.2x, 296.3x) from 2004 through 2007, ages 18-63 years, were selected from a claims database. Employees who initiated a third antidepressant following two antidepressant treatments of adequate dose and duration or who met published TRD criteria were classified as TRD likely (N = 2312). The index date was the date of the first antidepressant, starting 1/1/2004. The control group was an age- and sex-matched cohort of employees with MDD but without TRD. All had continuous eligibility during the 6-month pre-index (baseline) and 24-month post-index (study) period. McNemar tests were used to compare baseline comorbidities. Wilcoxon signed-rank tests were used to compare costs from employer perspective.

RESULTS

TRD-likely employees were on average 48 years old, and 64.8% were women. Compared with MDD controls, TRD-likely employees had significantly higher rates of mental-health disorders, chronic pain, fibromyalgia, and higher Charlson Comorbidity Index. Average direct 2-year costs were significantly higher for TRD-likely employees ($22,784) compared with MDD controls ($11,733), p < 0.0001. Average indirect costs were also higher among TRD-likely employees ($12,765) compared with MDD controls ($6885), p < 0.0001.

LIMITATIONS

Limitations of claims data related to accuracy of diagnosis coding and lack of clinical information apply to this study.

CONCLUSIONS

Based on comorbidities and healthcare resources used, patients with TRD appeared to represent a clinically complex subgroup of individuals with MDD. TRD was associated with significant cost burden.

Employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance

BACKGROUND

Treatment utilization/costs and work performance for persons with major depressive disorder (MDD) by severity of illness is not well documented.

METHODS

Using National Comorbidity Survey-Replication (2001-2002) data, US workforce respondents (n=4,465) were classified by clinical severity (not clinically depressed, mild, moderate, severe) using a standard self-rating scale [Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR)]. Outcomes included 12-month prevalence of medical services/medications use/costs and workplace performance. Treatment costs (employer's perspective) were estimated by weighing utilization measures by unit costs obtained for similar services used by MDD patients in claims data. Descriptive analysis across three severity groups generated chi(2) results.

RESULTS

Using a sample of 539 US workforce respondents with MDD, 13.8% were classified mild, 38.5% moderate, and 47.7% severe cases. Mental health services usage, including antidepressants, increased significantly with severity, with average treatment costs substantially higher for severe than for mild cases both regarding mental health services ($697 vs. $388, chi(2)=4.4, P=.019) and antidepressants ($256 vs. $88, chi(2)=9.0, P=.001). Prevalence rates of unemployment/disability increased significantly (chi(2)=11.7, P=.003) with MDD severity (15.7, 23.3, and 31.3% for mild, moderate, and severe cases). Severely and moderately depressed workers missed more work than nondepressed workers; the monthly salary-equivalent lost performance of $199 (severely depressed) and $188 (moderately depressed) was significantly higher than for nondepressed workers (chi(2)=10.3, P<.001). Projected to the US workforce, monthly depression-related worker productivity losses had human capital costs of nearly $2 billion.

CONCLUSIONS

MDD severity is significantly associated with increased treatment usage/costs, treatment adequacy, unemployment, and disability and with reduced work performance.

Olanzapine/fluoxetine: a review of its use in patients with treatment-resistant major depressive disorder

Olanzapine/fluoxetine (Symbyax) is an oral, once-daily, fixed-dose combination of the atypical antipsychotic olanzapine and the selective serotonin reuptake inhibitor (SSRI) fluoxetine. It is indicated, in adult patients, for the acute treatment of depressive episodes associated with bipolar I disorder and treatment-resistant major depressive disorder. In adult patients with treatment-resistant depression (major depressive disorder in adults who do not respond to two separate trials of different antidepressants of adequate dose and duration in the current episode), olanzapine plus fluoxetine combination therapy was generally more effective than either drug as monotherapy based on an integrated analysis of clinical trials of 8-12 weeks' duration. More limited data also indicate that longer-term treatment for 76 weeks with olanzapine plus fluoxetine was efficacious in this patient group. Combination therapy was generally well tolerated, with a tolerability profile similar to that of olanzapine monotherapy, although fluoxetine monotherapy was generally better tolerated than olanzapine plus fluoxetine. The combination of olanzapine plus fluoxetine, as a fixed-dose formulation, offers a useful treatment option in this difficult-to-treat patient group.

The 6-month persistence on SSRIs and associated economic burden

OBJECTIVES

To assess persistence on SSRIs (most prescribed antidepressants) and associated healthcare costs in a naturalistic setting.

METHODS

For this retrospective cohort study based on a US reimbursement claims database, all adults with a claim for a SSRI (citalopram, escitalopram, fluoxetine, paroxetine or sertraline) related to a diagnosis of depression were included. Patients should have had no previous reimbursement for any antidepressant within the previous 6 months. Non-persistence was defined as failing to renew prescription within 30 days in the 6-month period after the index date.

RESULTS

In the 45,481 patients included, persistence decreased from 95.5% at 1 month, to 52.6% at 2 months, 37.6% at 3 months and 18.9% at 6 months. Among factors associated with higher 6-month persistence were age 18-34 years, physician's specialty, treatment with escitalopram, absence of abuse history and psychotropic prescription history. During the 6-month after index date, healthcare costs tended to be higher in non-persistent than in persistent patients although not significantly (RR=1.05, adjusted p=0.055).

CONCLUSION

Despite some limitations associated with the use of computerized administrative claims data (residual unmeasured confounding), these results highlight a generally low persistence rate at 6 months. Special attention should be given to persistence on treatment, with consideration of potential antidepressant impact.

Scientific and ethical issues related to deep brain stimulation for disorders of mood, behavior, and thought

CONTEXT

A 2-day consensus conference was held to examine scientific and ethical issues in the application of deep brain stimulation for treating mood and behavioral disorders, such as major depression, obsessive-compulsive disorder, and Tourette syndrome.

OBJECTIVES

The primary objectives of the conference were to (1) establish consensus among participants about the design of future clinical trials of deep brain stimulation for disorders of mood, behavior, and thought and (2) develop standards for the protection of human subjects participating in such studies.

RESULTS

Conference participants identified 16 key points for guiding research in this growing field.

CONCLUSIONS

The adoption of the described guidelines would help to protect the safety and rights of research subjects who participate in clinical trials of deep brain stimulation for disorders of mood, behavior, and thought and have further potential to benefit other stakeholders in the research process, including clinical researchers and device manufactures. That said, the adoption of the guidelines will require broad and substantial commitment from many of these same stakeholders.

Antidepressant treatment patterns and costs among US employees

OBJECTIVE

To compare medical and cost profiles of patients treated for depression classified by treatment pattern groups.

METHODS

An analysis used de-identified 1999-2004 employer claims data (n=2.9 million beneficiaries) for employees with > or =1 diagnosis of major depressive disorder and > or =1 antidepressant prescription, following a 6-month washout period of no antidepressant prescription. Patients were classified into switcher/discontinuer/augmenter/maintainer during Healthcare Effectiveness Data and Information Set-defined initial and subsequent treatment periods, then grouped into stable, intermediate, or non-stable treatment groups, based on stability of treatment patterns. Medical/cost profiles for 6-month pre- and 12-month post-index periods were compared descriptively, and multivariate regressions were estimated, controlling for baseline characteristics/severity markers. Cost savings reflect differences between treatment pattern groups from a current US perspective.

RESULTS

Of the 5,225 patients meeting inclusion criteria, 60.8% were in stable, 24.5% in intermediate and 14.7% in non-stable treatment groups. No significant differences existed in medical profiles and costs between the three groups in the pre-index period. In the post-index period, stable group patients had lower costs compared to intermediate and non-stable groups. Stable group patients generated cost savings of $1,842 compared to intermediate and $5,231 compared to non-stable groups. Multivariate analysis confirmed these findings.

CONCLUSION

Patients on a more stable treatment regimen yield significant cost savings compared to patients on a less stable regimen.

Determinants of direct cost differences among US employees with major depressive disorders using antidepressants

OBJECTIVE

To understand factors driving the economic burden of major depressive disorder (MDD) patients with different treatment regimens, by evaluating the relationship between medical profiles and treatment costs.

METHODS

Claims data for US privately insured employees (1999-2004) were analysed. Analysis included adult employees with >/=1 diagnosis of MDD and >/=1 prescription for specific antidepressants following a 6-month washout period. Patients were first classified into treatment pattern groups (switchers/discontinuers/maintainers/augmenters), then stratified into mutually exclusive treatment groups - nonstable, stable and intermediate - based on evidence of stability in treatment therapy. Rates of mental and physical co-morbidities, injuries/accidents, substance abuse and urgent care use were analysed across treatment pattern groups. Direct (medical/drug) costs were calculated per patient per year and disaggregated into depression- and non-depression-related components. A two-part multivariate model controlled for baseline characteristics. Costs were also estimated for patients with MDD only, patients with MDD and generalized anxiety disorder (GAD), and patients with MDD and any type of anxiety.

RESULTS

Annual per patient adjusted costs (year 2005 values) were significantly lower among stable patients ($US6215) than among intermediate ($US7317) and nonstable patients ($US9948; p < 0.001). Stable patients also had lower depression- and non-depression-related costs. Patients with MDD and comorbid GAD or any type of anxiety had significantly higher costs than MDD-only patients.

CONCLUSIONS

Nonstability of treatment is associated with higher comorbidity rates, more urgent care use and higher total, depression- and non-depression-related direct costs. The stable group represents continuity of care and is associated with significant cost savings. Co-morbidities are associated with increased costs.

Serious life events among resistant and non-resistant MDD patients

BACKGROUND

Over 60% of patients with major depressive disorder (MDD) do not respond fully to therapy. Half of them eventually will not respond at all and will be referred to as treatment resistant depression (TRD) patients. Stressful life events were found to be associated with MDD and were also found to affect the course of the disease. We hypothesize that negative life events might be an independent risk factor for TRD.

METHODS

One hundred and seven unipolar MDD patients, all treated for at least 4 weeks, were enrolled in the study. Patients were assessed on their psychiatric and medical history, and seven categories of stressful life events.

RESULTS

39.3% of participants were defined as TRD patients and 60.7% as non-TRD. TRD patients had more severe depression, more past suicide attempts, more hospitalizations, longer episodes, and received more benzodiazepines, antipsychotics, and ECT. Job loss and financial stress were more prevalent among the TRD group. Overall, the TRD patients had more negative life events than responders.

LIMITATIONS

This is a retrospective study. In addition, the definition of TRD was done dichotomically, therefore the association between number of stressful life events and the degree of resistance was not tested.

CONCLUSIONS

Job loss and financial distress were found to predict TRD. The loss of a parent and severe health conditions were not associated with TRD, suggesting that events affecting the development of MDD, do not necessarily affect the treatment outcome.

Estimating the potential savings with vagus nerve stimulation for treatment-resistant depression: a payer perspective

OBJECTIVE

To provide a formula estimating potential reductions in healthcare utilization costs with adjunctive vagus nerve stimulation (VNS Therapy) in treatment-resistant depression (TRD).

METHODS

This payer-perspective formula incorporates costs of treatment as usual for TRD patients from a published analysis of the MarketScan private payer claims database and the 2004 Medicare 5% standard analytic file. Estimated remission and response rates are from the published VNS pilot and pivotal studies. Costs were converted to 2008 US dollars per the US Bureau of Labor Statistics medical care costs, consumer price index. Device and implantation costs were calculated at $28,336.

RESULTS

From the MarketScan and pooled outcomes data (VNS pilot and pivotal studies), potential per patient savings (hospitalization directly and indirectly related to depression) was $2974 at 5 years of device life, $23,539 at 8 years (moderate cost reduction scenario); $12,914 at 5 years, $40,935 at 8 years (optimistic scenario). Corresponding break-even device life was 4.57 and 3.62 years, respectively. From the Medicare file and pooled outcomes, potential per patient savings (inpatient and outpatient directly and indirectly related to depression) was $8358 at 5 years of device life, $32,385 at 8 years (moderate scenario); $19,837 at 5 years, $52,473 at 8 years (optimistic scenario). Corresponding break-even device life was 3.96 and 3.18 years, respectively.

CONCLUSIONS

The formula allows an evaluation of expected reductions in healthcare costs as a function of input cost variables, efficacy rates, and benefit scenarios. Cited costs differ relative to care settings, diagnostic principles, and procedural volume. This formula can help assess moderate-to-longer-term economic benefits of VNS for a particular institution. Results suggested that potential reductions in healthcare costs with VNS for TRD may be substantial. Break-even device life for the scenarios presented ranges between 2.3 and 5.7 years.

The economic burden associated with SSRI treatment failure in a managed care population

OBJECTIVE

The objective of this study was to describe the economic burden to managed care associated with failure of selective serotonin reuptake inhibitor (SSRI) therapy in terms of direct medical costs.

METHODS

A retrospective analysis of the PharMetrics database, a national managed care medical and pharmacy claims dataset of 1.9 million major depressive disorder patients between January 2003 and June 2005 was conducted. A pre-post comparison of annual medical cost increases following new SSRI treatment was performed and differences in mean cost increases for the SSRI-failure versus non-failure groups were calculated using t-tests and confirmed using multivariate linear regression.

RESULTS

The percentage of subjects with likely SSRI treatment failure was 30.7% (n=2,595). The two groups were statistically similar (p>0.05) in age, gender distribution and insurance status. The mean increase in total direct medical costs was $6,489 versus $3,257 for the SSRI treatment failure and non-failure cohorts, respectively. The major components of these cost increases were outpatient cost ($2,579 vs. $1,309) and inpatient cost ($2,862 vs. $1,532), between the SSRI treatment failure and non-failure cohorts, respectively. All differences remained statistically significant at p<0.001, even after controlling for potential confounders.

CONCLUSIONS

This descriptive study found that increased costs of major depressive disorder are substantial following the onset of a new SSRI treatment episode and significantly higher among patients with likely SSRI treatment failure.

Genetic screening for SSRI drug response among those with major depression: great promise and unseen perils

This article examines evidence for the potential benefit of genetic testing for SSRI response, as well as potential ethical and practical implications of the implementation of this test into standard psychiatric practice. We reviewed three areas of the literature: the burden of treatment-resistant and treatment-intolerant major depressive disorders, the evidence for the value of genetic testing to predict drug response, and the ethical and practical issues of genetic testing in usual care. Treatment resistance and treatment intolerance are common for persons treated with selective serotonin reuptake inhibitors (SSRIs) and are associated with both financial and quality-of-life costs. There is strong evidence from association studies that some polymorphisms are associated with SSRI response. However, no randomized trials have yet tested the efficacy of genetic tests to improve outcome in those with treatment resistance or treatment intolerance to SSRIs. Given the nonspecific nature of the test proposed, several ethical concerns are also involved with administering the genetic tests to patients. A randomized trial comparing response in those treated with standard psychiatric care and in those treated with psychiatric care tailored as a result of genetic test results should be completed before the implementation of these tests can be considered. Additionally, the ethical and practical questions concerning the tests must be addressed now, so that the potential impact of these tests on patient care can be well understood prior to adoption in standard practice.

Monoamine metabolites level in CSF is related to the 5-HTT gene polymorphism in treatment-resistant depression

The serotonin (5-hydroxytryptamine) transporter (5-HTT) is considered to affect the pathogenesis of mood disorders. Large number of genetic association studies between 5-HTT functional polymorphisms and vulnerability of mood disorders and therapeutic response to antidepressants has been carried out. We investigated the influence of 5-HTT-linked polymorphic region (5-HTTLPR) and 5-HTT 17 bp variable number of tandem repeat polymorphism (5-HTTVNTR) polymorphisms on concentrations of monoamine metabolites in cerebrospinal fluid (CSF) among treatment-resistant patients with mood disorders. Subjects were 119 Swedish patients with persistent mood disorders and 141 healthy subjects. In 112 of these patients, we measured 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid (HVA), and 3-methoxy-4-hydroxyphenylglycol in CSF. Genotyping for 5-HTT polymorphisms from genomic DNA was carried out by PCR. There was no significant difference in allele/genotype frequency between patients and healthy subjects. In patients with mood disorders, we found significant difference in mean 5-HIAA concentration between 5-HTTLPR genotypes (p=0.03). Although the 5-HIAA concentration showed a tendency to be higher in short (S) carriers than in non-S carriers of the 5-HTTLPR in patients (p=0.06), when considering patients with major depressive disorder (MDD), the 5-HIAA concentration was significantly higher among S carriers than among non-S carriers (p=0.02). Moreover, the 5-HIAA concentration was higher in S/S subjects compared to long (L)/L (p=0.0001) and L/S (p=0.002) subjects in patients with MDD. Similarly, there was higher HVA concentration in S/S subjects compared to L/L (p=0.002) and L/S subjects (p=0.002). There was no effect of 5-HTTVNTR. Our findings show that the 5-HTTLPR polymorphism affects 5-HIAA and HVA concentrations among treatment-resistant patients with mood disorders.

Family therapy for depression

BACKGROUND

People with depression often experience interpersonal problems. Family therapy for depression is a widely used intervention, but it is unclear whether this is an effective therapy for the treatment of depression.

OBJECTIVES

To assess the efficacy of family therapy for depression.

SEARCH STRATEGY

The following electronic databases were searched using a specific search strategy: CCDANCTR-Studies and CCDANCTR-References searched on 21/10/2005, The Cochrane Central Register of Controlled Trials, Medline (1966 to January 2005), EMBASE (1980 to January 2005), Psycinfo (1974 to January 2005). Reference lists of articles were also searched. Handsearches of relevant journals and bibliographies were conducted and first authors of included studies and experts in the field were contacted for further information.

SELECTION CRITERIA

Included studies were randomised controlled and controlled clinical trials comparing family therapy with no intervention or an alternative intervention in which depression symptomatology was a main outcome measure.

DATA COLLECTION AND ANALYSIS

Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of the selected trials were independently extracted by three review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. It was not possible to perform meta-analyses because of the heterogeneity of the selected studies.

MAIN RESULTS

Three high-quality and three low-quality studies, involving 519 people with depression, were identified. The studies were very heterogeneous in terms of interventions, participants, and measuring instruments. Despite fairly good methodological quality and positive findings of some studies, evidence for the effectiveness of family therapy for depression did not exceed level 3 (limited or conflicting evidence), except for moderate evidence (level 2), based on the non-combined findings from three studies, indicating that family therapy is more effective than no treatment or waiting list condition on decreasing depression, and on increasing family functioning.

AUTHORS' CONCLUSIONS

The current evidence base is too heterogeneous and sparse to draw conclusions on the overall effectiveness of family therapy in the treatment of depression. At this point, use of psychological interventions for the treatment of depression for which there is already an evidence-base would seem to be preferable to family therapy. Further high quality trials examining the effectiveness and comparative effectiveness of explicitly defined forms of family therapy are required.

Psychosocial impairment and treatment utilization by patients with borderline personality disorder, other personality disorders, mood and anxiety disorders, and a healthy comparison group

This study compared psychosocial functioning and treatment utilization in 130 participants who were diagnosed with a borderline personality disorder (BPD), a non-BPD personality disorder (OPD), a mood and/or anxiety disorder (MAD), or had no current psychiatric diagnosis and served as a healthy comparison group. Diagnostic and Statistical Manual of Mental Disorders (4th Edition) diagnoses, psychosocial functioning, and treatment utilization were determined by using well-established semistructured research interviews conducted by trained doctoral-level clinicians. Analysis of variance revealed the most severe deficits in functioning characterized the BPD group across areas of global functioning with more moderate impairments in functioning occurring in OPD and MAD groups. The BPD group was characterized by significantly greater psychiatric and nonpsychiatric treatment utilization than the other groups. These findings indicate that BPD as well as other personality disorders are a source of considerable psychologic distress and functional impairment equivalent to, and at times exceeding, the distress found in mood and anxiety disorders. The public health impact of BPD diagnosis is highlighted by the high rates of psychiatric and nonpsychiatric treatment utilization.

Quetiapine augmentation of treatment-resistant depression: a comparison with lithium

OBJECTIVE

The prevalence of and morbidity associated with treatment-resistant depression has motivated the exploration of treatment alternatives. In this study, quetiapine was compared with lithium in the augmentation of treatment-resistant depression.

RESEARCH DESIGN AND METHODS

Open-label, comparative study in 20 patients with major depression who had failed to respond after 4 weeks of treatment with an antidepressant at the maximal recommended dose. Patients were randomised to either lithium or quetiapine in addition to the maximally dosed antidepressant and any other concurrent medications. Lithium was initiated at 600 mg/day; quetiapine was titrated to 400 mg by day 7.

RESULTS

Depression, measured by the Hamilton Depression Rating Scale (HAM-D), significantly improved from baseline in both quetiapine (F(1,90) = 25.11, p < 0.0001) and lithium (F(1,90) = 34.54, p < 0.0001). The difference in improvement between the two groups began at day 14 and was seen at all timepoints thereafter (p < 0.05), with the quetiapine group showing greater improvement than the lithium group. In the Montgomery-Asberg Depression Rating Scale (MADRS) analysis, the difference between the quetiapine and lithium group was significant from day 28 onwards (p < 0.05), with subjects improving more in the quetiapine group than the lithium group. The treatment by week interaction showed a significant difference overall between the two groups (p < 0.0001). The severity of psychomotor retardation showed a significant decrease in the Widlocher Psychomotor Retardation Scale scores in the quetiapine (p < 0.0001) and lithium (p < 0.0001) groups.

CONCLUSIONS

In this pilot study, quetiapine was an effective augmenting agent in treatment-resistant depression.

Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment

Depression is a highly prevalent condition that results in substantial functional impairment. Advocates have attempted in recent years to make the 'business case' for investing in quality improvement efforts in depression care, particularly in primary care settings. The business case suggests that the costs of depression treatment may be offset by gains in worker productivity and/or reductions in other healthcare spending. In this paper, we review the evidence in support of this argument for improving the quality of depression treatment. We examined the impact of depression on two of the primary drivers of the societal burden of depression: healthcare utilisation and worker productivity. Depression leads to higher healthcare utilisation and spending, most of which is not the result of depression treatment costs. Depression is also a leading cause of absenteeism and reduced productivity at work. It is clear that the economic burden of depression is substantial; however, critical gaps in the literature remain and need to be addressed. For instance, we do not know the economic burden of untreated and/or inappropriately treated versus appropriately treated depression. There remain considerable problems with access to and quality of depression treatment. Progress has been made in terms of access to care, but quality of care is seldom consistent with national treatment guidelines. A wide range of effective treatments and care programmes for depression are available, yet rigorously tested clinical models to improve depression care have not been widely adopted by healthcare systems. Barriers to improving depression care exist at the patient, healthcare provider, practice, plan and purchaser levels, and may be both economic and non-economic. Studies evaluating interventions to improve the quality of depression treatment have found that the cost per QALY associated with improved depression care ranges from a low of 2519 US dollars to a high of 49,500 US dollars. We conclude from our review of the literature that effective treatment of depression is cost effective, but that evidence of a medical or productivity cost offset for depression treatment remains equivocal, and this points to the need for further research in this area.

Neurostimulation in resistant depression

Drugs and psychotherapy are inadequate for relieving depressive symptoms in a substantial portion of severely depressed patients. In that patient group, neurostimulation techniques such as electroconvulsive therapy, transcranial magnetic stimulation, magnetic seizure therapy, vagus nerve stimulation and deep brain stimulation could be lifesaving therapies. Neurostimulation is a physical intervention that utilizes application of either electric current or a magnetic field to directly stimulate the brain or central nervous system. This article presents an overview of currently available neurostimulatory techniques for depression, including a review of their efficacy and safety. Further development and evaluation of non-pharmacological antidepressant therapies are needed, with the hope of improving treatment of refactory depression.

Safety and efficacy of repetitive transcranial magnetic stimulation in the treatment of depression: a critical appraisal of the last 10 years

Depression is a common and debilitating illness, for which alternative treatments are urgently needed. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive and relatively painless experimental technique of altering brain physiology. The authors critically review the evidence for the efficacy, safety and tolerability of rTMS in the treatment of depression based on published data over the last decade. They also discuss studies which have examined relevant clinical, demographic, methodological, and technical parameters that might be implicated in optimizing the antidepressant efficacy of this technique. rTMS depression trials conducted through early 2006 are included in this review, which focuses mainly on the results of published sham-controlled studies, literature reviews and meta-analyses. Trials published so far have been characterized by the use of a great variety of stimulation parameters, study designs, questionable sham controls, small sample sizes and heterogeneously depressed populations, all of which have made comparisons between studies difficult. Meta-analyses of 2-week rTMS sham-controlled studies support, for the most part, the antidepressant effects of rTMS which are statistically superior to sham. However, the degree of clinical improvement remains small, although greater efficacy has been shown with longer treatment courses and predictors of response to rTMS are progressively being identified. rTMS is a promising antidepressant treatment with overall minor adverse effects. Because the clinical efficacy of rTMS as an antidepressant remains questionable, further systematic, large-scale multicenter studies comparing rTMS to a sham and/or to an antidepressant medication along with more stringent stimulation parameters are warranted in order to identify patient populations most likely to benefit and treatment parameters most likely to optimize its antidepressant efficacy.