A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine

Adherence behaviour with psychotropic medication is a form of self-medication

Adherence with psychotropic medication is at least at poor as adherence with medication for physical health problems. There has been an assumption this was due to loss of insight resulting from psychiatric disorders themselves. Consequently, interventions have focussed on treating the underlying psychiatric disorder and generating psychological strategies to promote awareness. Recent surveys of patient preferences for information and involvement in health care decisions highlight that most individuals want to participate in the process of medical care. Patients often have strong pre-existing beliefs about different therapeutic options. This is supported by the self-determination theory which distinguishes between autonomous behaviour and behaviours that are influenced by external forces. When considering the patient perspective in medication adherence, it is useful to consider the self-medication hypothesis. This can equally be applied to prescribed and non-prescribed drugs. The self-medication hypothesis states that patients decide to start, adjust or stop prescribed medication according to perceived health needs. Such decisions are often conducted intentionally and rationally, given the information available to the patient and their understanding of their condition. In this narrative review, the evidence for and against intentionality in psychotropic adherence behaviour is examined. Studies of compliance and related predictors are examined in depression, schizophrenia and bipolar affective disorder. Results suggest that although concordance depends on patient, illness and clinician factors, patient choice is usually the final common pathway. Illness severity and insight is important in some cases but can act in concert with cognitive factors. Individuals appear to prefer to take medication "as required" (symptomatically) rather than prophylactically. Significant influences upon self-medication habits are prior health beliefs, medication attitudes, adverse effects and adequacy of communication from the health care professional. The self-medication hypothesis applied to prescribed psychotropic medication should assist rather than heed clinicians in improving adherence by taking a patient centred approach and where possible promoting patient autonomy.

Cost-utility of selective serotonin reuptake inhibitors for depression in primary care in Catalonia

OBJECTIVE

To determine the cost-utility of selective serotonin reuptake inhibitors (SSRIs) for treating depressive disorders prescribed in primary care (PC).

METHOD

A total of 301 participants beginning antidepressant treatment with an SSRI were enrolled in a prospective 6-month follow-up naturalistic study. Incremental cost-utility ratios (ICUR) were obtained for several comparisons among different SSRIs. To address uncertainty in the ICUR's sampling distribution, non-parametric bootstrapping was carried out.

RESULTS

Taking into account adjusted total costs and incremental quality of life gained, fluoxetine dominated paroxetine and citalopram with 63.4% and 79.3% of the bootstrap replications in the dominance quadrant, respectively. Additionally, fluoxetine was cost-effective over sertraline with 83.4% of the bootstrap replications below the threshold of 33,936 US$/quality-adjusted life year (30,000 euro/QALY).

CONCLUSION

Fluoxetine seems to be a better cost-utility SSRI option for treating depressive disorders in PC.

The mission is remission: health economic consequences of achieving full remission with antidepressant treatment for depression

The aim of the present study was to determine the magnitude of the impact of treating depression to full remission on cost and health-related quality of life. In a naturalistic longitudinal survey recordings of resource use and quality of life were carried out among depressed patients treated with antidepressant therapy in 56 Swedish primary care clinics. We found that a total of 52% of the patients achieved full remission during the study period. Remitting patients had, on average, three outpatient visits less than non-remitting patients (p < 0.01), 22 fewer sick leave days (p = 0.01), which translated into a significantly lower total cost (Euro 2700) compared with non-remitting patients (p < 0.01). Health-related quality-of-life scores improved by 40% for remitting patients when compared with non-remitting ones (p < 0.01). We conclude that remission has a substantial health economic impact on patients treated for depression, which further strengthens the importance of aiming for full remission in the treatment of depression.

Comparison of general practitioner records and patient self-report questionnaires for estimation of costs

This study compared resource use data and estimated costs over a 12-month period, based on patient self-report questionnaires and general practitioner records. The level of agreement was measured by weighted kappa. Differences in total costs were plotted against mean total costs. Of 324 patients with complete GP records for the period only 85 (26.2%) had complete self-report data. The recorded number of contacts per patient was higher for patient questionnaires than GP records (17.20 vs. 12.64), and the level of agreement between the two sources was moderate (kappa(w)=0.465). The plots of differences in total costs showed a slight downward bias, suggesting that estimation of total cost from GP records is lower than patient questionnaires. The incompleteness of patient questionnaires forces reliance on GP records as the main source of information for economic evaluations.