The economic burden of depression and the cost-effectiveness of treatment

Prevalence and treatment of mental disorders, 1990 to 2003

BACKGROUND

Although the 1990s saw enormous change in the mental health care system in the United States, little is known about changes in the prevalence or rate of treatment of mental disorders.

METHODS

We examined trends in the prevalence and rate of treatment of mental disorders among people 18 to 54 years of age during roughly the past decade. Data from the National Comorbidity Survey (NCS) were obtained in 5388 face-to-face household interviews conducted between 1990 and 1992, and data from the NCS Replication were obtained in 4319 interviews conducted between 2001 and 2003. Anxiety disorders, mood disorders, and substance-abuse disorders that were present during the 12 months before the interview were diagnosed with the use of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Treatment for emotional disorders was categorized according to the sector of mental health services: psychiatry services, other mental health services, general medical services, human services, and complementary-alternative medical services.

RESULTS

The prevalence of mental disorders did not change during the decade (29.4 percent between 1990 and 1992 and 30.5 percent between 2001 and 2003, P=0.52), but the rate of treatment increased. Among patients with a disorder, 20.3 percent received treatment between 1990 and 1992 and 32.9 percent received treatment between 2001 and 2003 (P<0.001). Overall, 12.2 percent of the population 18 to 54 years of age received treatment for emotional disorders between 1990 and 1992 and 20.1 percent between 2001 and 2003 (P<0.001). Only about half those who received treatment had disorders that met diagnostic criteria for a mental disorder. Significant increases in the rate of treatment (49.0 percent between 1990 and 1992 and 49.9 percent between 2001 and 2003) were limited to the sectors of general medical services (2.59 times as high in 2001 to 2003 as in 1990 to 1992), psychiatry services (2.17 times as high), and other mental health services (1.59 times as high) and were independent of the severity of the disorder and of the sociodemographic characteristics of the respondents.

CONCLUSIONS

Despite an increase in the rate of treatment, most patients with a mental disorder did not receive treatment. Continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatments.

Comparison of the effects of mirtazapine and fluoxetine in severely depressed patients

INTRODUCTION

Depression is a major global problem associated with large medical, sociological and economic burdens. Mirtazapine (Remeron, Organon NV, The Netherlands) is an antidepressant with a unique mechanism of action that has similar or superior efficacy to TCAs and SSRIs in moderate-to-severe depression. However, this agent has not yet been tested in patients with severe depression alone.

OBJECTIVE

To compare the antidepressant efficacy and tolerability of mirtazapine and fluoxetine and their effects on anxiety and quality of life in patients with severe depression (> or = 25 points on the first 17 items of the Hamilton Depression Rating Scale [HDRS-17]).

METHODS

In this double-blind study, 297 severely depressed patients were randomised to receive mirtazapine 15-60 mg/day (n = 147) or fluoxetine 20-40 mg/day (n = 152) for 8 weeks. 294 subjects were actually treated and 292 included in the intent-to-treat population. Symptom severity was measured by the HDRS-17, Montgomery-Asberg Depression Rating Scale (MADRS) and Clinical Global Impression (CGI) rating scale. Quality of life was self-assessed by patients using the Leeds Sleep Evaluation Questionnaire and the Quality of Life, Enjoyment and Satisfaction Questionnaire. Adverse events were recorded throughout the study.

RESULTS

No statistically significant differences were noted between the two groups in change from baseline HDRS-17 score at any time point; both treatments were associated with large (approximately 15 points) decreases by study end. However, more mirtazapine-treated patients tended to exhibit a > or = 50% decrease in HDRS score (significant at day 7; 9.0% vs 0.7%, p = 0.002). Significant differences in favour of mirtazapine were also observed at day 14 for changes in MADRS scores (-10.9 vs -8.5, p = 0.006) and the proportion of patients with > or = 50% decrease in MADRS score (21.4% vs 10.9%, p = 0.031). On the CGI, the proportion of 'much/very much improved' patients tended to be greater with mirtazapine (significant at day 7; 9.7% vs 3.4%, p = 0.032). No significant between-group differences were observed for the majority of quality-of-life measures. However, mirtazapine produced significantly better improvements on 'sleeping assessment 1' (14.9 +/- 5.2 vs 13.7 +/- 5.4, p = 0.028) and 'sleeping assessment 2' (p = 0.013) than fluoxetine. Both agents were generally well tolerated but mirtazapine-treated patients experienced a mean weight gain of 0.8 +/- 2.7 kg compared with a mean decrease in weight of 0.4 +/- 2.1 kg for fluoxetine-treated patients (p < 0.001).

CONCLUSIONS

Mirtazapine is as effective and well tolerated as fluoxetine in the treatment of patients with severe depression.

Cost-effectiveness of escitalopram versus citalopram in the treatment of severe depression

BACKGROUND

Severe depression is associated with an extensive economic burden on both the patient and society.

OBJECTIVE

To estimate the cost-effectiveness in Austria of escitalopram compared with citalopram in the management of severe depression (Montgomery-Asberg Depression Rating Scale score > or =30).

METHODS

A decision model incorporated treatment paths and associated direct resource use (psychiatric hospitalization, medications, general practitioner and psychiatrist visits, treatment discontinuation, suicide attempts) associated with managing severe depression and the indirect cost of work absenteeism over a 6-month period. Main outcomes were clinical success (remission at 6 mo) and cost (2002 Euros equals approximately 1.25 US) of treatment. The analysis was performed from the Austrian societal and Social Healthcare Insurance System (SHIS) perspectives. Clinical input data were derived from a meta-analysis of 8-week randomized clinical trials. Costs were derived from standard Austrian price lists or from the literature.

RESULTS

Six months after the start of treatment, the overall clinical success remission rate was higher for escitalopram (53.7%) than for citalopram (48.7%). From the SHIS perspective, the total expected cost per successfully treated severely depressed patient was 924 (32.1%) lower for escitalopram (2879) compared with citalopram (3803). From the societal perspective, the total expected cost per successfully treated severely depressed patient was 1369 (24.4%) lower for escitalopram (5610) than for citalopram (6979). Sensitivity analyses demonstrated that the model was robust and that, even if citalopram had no acquisition cost, escitalopram remained the dominant strategy for both perspectives.

CONCLUSIONS

Treatment with escitalopram was the dominant strategy. These data suggest that escitalopram is a cost-effective antidepressant compared with citalopram in the management of severe depression in Austria.