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Davis O, Dawson J, Degerdon L, Delgadillo J, Kadam U, Nielsen K, Sinclair A, Yarker J, Munir F. Protocol for a pilot cluster randomised controlled trial of a multicomponent sustainable return to work IGLOo intervention. Pilot Feasibility Stud 2024; 10:23. [PMID: 38308380 PMCID: PMC10837924 DOI: 10.1186/s40814-023-01439-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 12/21/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Long-term sickness costs businesses in the United Kingdom (UK) approximately £7 billion per annum. Most long-term sickness absences are attributed to common mental health conditions, which are also highly prevalent in people with acute or musculoskeletal health conditions. This study will pilot the IGLOo (Individual, Group, Leaders, Organisation, overarching context) intervention which aims to support workers in returning to and remaining in work following long-term sickness absence. The potential impact of the intervention is a timely return to work (main trial primary outcome) and prevention of a further episode of long-term sick leave. The intervention will be piloted in a randomised controlled trial (RCT) to examine the feasibility of the intervention (pilot trial primary outcome) and to inform a fully powered definitive trial to evaluate sustainable return to work (RTW) in people with primary or secondary mental ill-health who go on long-term sick leave. METHODS AND DESIGN A two-arm feasibility randomised controlled trial (with a 30-month study period including 12-month follow-up) of the IGLOo intervention will be conducted in large organisations (≥ 600 workers) from the Yorkshire and Humberside regions, in the UK. Eight consenting organisations will be recruited and randomised to the intervention or control arms of the study (1:1 ratio), with a minimum recruitment target of 13 workers eligible to participate from each. Organisations assigned to the control group will continue with their usual practice. Feasibility data will include data collected on recruitment, retention and attrition of participants; completion of research outcome measures; and intervention compliance. Measurements of mental health, RTW, work outcomes, quality-of-life, workplace support and communication and other demographic data will be taken at baseline, 3, 6, 9 and 12 months in all participants. Qualitative interviews and survey data with all participants will explore the experiences of participants, acceptability of the intervention components and evaluation measures. Exploratory economic evaluation will be conducted to further inform a definitive trial. DISCUSSION The findings from this pilot study will help to inform the development of a definitive cluster RCT designed to examine the efficacy of this intervention on health and work-related outcomes in UK workers on long-term sick leave. TRIAL REGISTRATION ISRCTN11788559 (prospectively registered, date registered 6 October 2022).
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Affiliation(s)
- Oliver Davis
- Grounded Research Team, Rotherham Doncaster and South Humber NHS Trust, Doncaster, UK
| | - Jeremy Dawson
- Sheffield University Management School, University of Sheffield, Sheffield, UK
| | - Lizzie Degerdon
- Grounded Research Team, Rotherham Doncaster and South Humber NHS Trust, Doncaster, UK
| | - Jaime Delgadillo
- Grounded Research Team, Rotherham Doncaster and South Humber NHS Trust, Doncaster, UK
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Umesh Kadam
- Department of Health and Community Sciences, University of Exeter, Exeter, UK
| | - Karina Nielsen
- Institute of Work Psychology, University of Sheffield, Sheffield, UK
| | - Alice Sinclair
- School of Sport, Health and Exercise Science, Loughborough University, Loughborough, UK
| | | | - Fehmidah Munir
- School of Sport, Health and Exercise Science, Loughborough University, Loughborough, UK.
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Jelovac A, McCaffrey C, Terao M, Shanahan E, Mohamed E, Whooley E, McDonagh K, McDonogh S, Igoe A, Loughran O, Shackleton E, O'Neill C, McLoughlin DM. Study protocol for Ketamine as an adjunctive therapy for major depression (2): a randomised controlled trial (KARMA-Dep [2]). BMC Psychiatry 2023; 23:850. [PMID: 37974160 PMCID: PMC10655414 DOI: 10.1186/s12888-023-05365-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Depression is a common psychiatric disorder and a leading cause of disability worldwide. Conventional monoaminergic antidepressants have limited efficacy and take weeks to exert a therapeutic effect. Single infusions of subanaesthetic doses of ketamine exhibit rapid antidepressant action but effects are transient and relapse is common. One potential strategy for increasing ketamine's antidepressant efficacy and/or prolonging its therapeutic benefit may be serial infusions. There is limited evidence on the efficacy and safety of repeated ketamine infusions against an active comparator. METHODS This protocol describes an ongoing pragmatic, randomised, controlled, parallel-group, patient- and rater-blind, superiority trial. Eligible adult inpatients with a confirmed DSM-5 diagnosis of a major depressive episode (unipolar or bipolar) are randomly allocated in a 1:1 ratio to a course of up to eight infusions of ketamine or midazolam twice-weekly over four weeks. The primary objective is to assess the efficacy of serial adjunctive ketamine infusions versus active comparator midazolam by measuring Montgomery-Åsberg Depression Rating Scale score difference between arms from before the first infusion to 24 h after the final infusion, supplemented by a 95% confidence interval. To facilitate generalisability of results, the trial takes place under "real world" conditions with both groups continuing to receive regular inpatient care including treatment-as-usual pharmacotherapy, nursing care, and psychological and other therapies during the randomised treatment phase and regular outpatient care thereafter. Participants are monitored for relapse during a 24-week follow-up after the end of the randomised phase. Secondary objectives of the trial are to assess: response and remission rates at the end of randomised phase; relapse status during the 24-week follow-up after the end of the randomised phase; the safety and tolerability of repeated ketamine infusions regarding psychotomimetic and other psychiatric side effects, cognitive side effects, as well as withdrawal symptoms, haemodynamic stability, neurological, urological, and other physical side effects; and quality of life and cost-effectiveness. DISCUSSION There is an unmet clinical need for rapidly-acting novel antidepressants. This trial will provide efficacy, safety and health economic data on serial ketamine infusions and thus help inform clinical practice on the potential role of this treatment in the management of depression. TRIAL REGISTRATION EudraCT 2019-003109-92. Registered 2 October 2019. CLINICALTRIALS gov NCT04939649. Registered 25 June 2021.
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Affiliation(s)
- Ana Jelovac
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Cathal McCaffrey
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Masashi Terao
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Enda Shanahan
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Enas Mohamed
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Emma Whooley
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Kelly McDonagh
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Sarah McDonogh
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Anna Igoe
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Orlaith Loughran
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Ellie Shackleton
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland
| | - Ciaran O'Neill
- Centre for Public Health, Global Research Institute for Health Sciences, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Declan M McLoughlin
- Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital, James Street, Dublin, D08 K7YW, Ireland.
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.
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Pokhilenko I, Janssen LMM, Paulus ATG, Drost RMWA, Hollingworth W, Thorn JC, Noble S, Simon J, Fischer C, Mayer S, Salvador-Carulla L, Konnopka A, Hakkaart van Roijen L, Brodszky V, Park AL, Evers SMAA. Development of an Instrument for the Assessment of Health-Related Multi-sectoral Resource Use in Europe: The PECUNIA RUM. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:155-166. [PMID: 36622541 PMCID: PMC9931843 DOI: 10.1007/s40258-022-00780-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Measuring objective resource-use quantities is important for generating valid cost estimates in economic evaluations. In the absence of acknowledged guidelines, measurement methods are often chosen based on practicality rather than methodological evidence. Furthermore, few resource-use measurement (RUM) instruments focus on the measurement of resource use in multiple societal sectors and their development process is rarely described. Thorn and colleagues proposed a stepwise approach to the development of RUM instruments, which has been used for developing cost questionnaires for specific trials. However, it remains unclear how this approach can be translated into practice and whether it is applicable to the development of generic self-reported RUM instruments and instruments measuring resource use in multiple sectors. This study provides a detailed description of the practical application of this stepwise approach to the development of a multi-sectoral RUM instrument developed within the ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) project. METHODS For the development of the PECUNIA RUM, the methodological approach was based on best practice guidelines. The process included six steps, including the definition of the instrument attributes, identification of cost-driving elements in each sector, review of methodological literature and development of a harmonized cross-sectorial approach, development of questionnaire modules and their subsequent harmonization. RESULTS The selected development approach was, overall, applicable to the development of the PECUNIA RUM. However, due to the complexity of the development of a multi-sectoral RUM instrument, additional steps such as establishing a uniform methodological basis, harmonization of questionnaire modules and involvement of a broader range of stakeholders (healthcare professionals, sector-specific experts, health economists) were needed. CONCLUSION This is the first study that transparently describes the development process of a generic multi-sectoral RUM instrument in health economics and provides insights into the methodological aspects and overall validity of its development process.
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Affiliation(s)
- Irina Pokhilenko
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands.
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Luca M M Janssen
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Aggie T G Paulus
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
- School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - Ruben M W A Drost
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
| | - William Hollingworth
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanna C Thorn
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Claudia Fischer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Susanne Mayer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Luis Salvador-Carulla
- Mental Health Policy Unit, Faculty of Health, Health Research Institute, University of Canberra, Canberra, ACT, Australia
- School of Public Health, Menzies Centre for Health Policy, University of Sydney, Sydney, NSW, Australia
| | - Alexander Konnopka
- Department of Health Economics and Health Services Research, University Medical Center Hamburg, Hamburg, Germany
| | - Leona Hakkaart van Roijen
- Erasmus School of Health Policy and Management, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - Valentin Brodszky
- Department of Health Policy, Corvinus University of Budapest, Budapest, Hungary
| | - A-La Park
- Department of Health Policy, Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Silvia M A A Evers
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
- Trimbos Institute National Institute of Mental Health and Addiction, Utrecht, The Netherlands
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Schrag A, Carroll C, Duncan G, Molloy S, Grover L, Hunter R, Brown R, Freemantle N, Whipps J, Serfaty MA, Lewis G. Antidepressants Trial in Parkinson's Disease (ADepT-PD): protocol for a randomised placebo-controlled trial on the effectiveness of escitalopram and nortriptyline on depressive symptoms in Parkinson's disease. BMC Neurol 2022; 22:474. [PMID: 36510237 PMCID: PMC9743717 DOI: 10.1186/s12883-022-02988-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Depressive symptoms are common in patients with Parkinson's disease and depression is a significant predictor of functional impairment, reduced quality of life and general well-being in Parkinson's disease. Despite the high prevalence of depression, evidence on the effectiveness and tolerability of antidepressants in this population is limited. The primary aim of this trial is to establish the clinical and cost effectiveness of escitalopram and nortriptyline for the treatment of depression in Parkinson's disease. METHODS This is a multi-centre, double-blind, randomised placebo-controlled trial in 408 people with Parkinson's disease with subsyndromal depression, major depressive disorder or persistent depressive disorder and a Beck Depression Inventory-II (BDI-II) score of 14 or above. Participants will be randomised into one of three groups, receiving either escitalopram, nortriptyline or placebo for 12 months. Trial participation is face-to-face, hybrid or remote. The primary outcome measure is the BDI-II score following 8 weeks of treatment. Secondary outcomes will be collected at baseline, 8, 26 and 52 weeks and following withdrawal, including severity of anxiety and depression scores as well as Parkinson's disease motor severity, and ratings of non-motor symptoms, cognitive function, health-related quality of life, levodopa-equivalence dose, changes in medication, overall clinical effectiveness, capability, health and social care resource use, carer health-related quality of life, adverse effects and number of dropouts. DISCUSSION This trial aims to determine the effectiveness of escitalopram and nortriptyline for reducing depressive symptoms in Parkinson's disease over 8 weeks, to provide information on the effect of these medications on anxiety and other non-motor symptoms in PD and on impact on patients and caregivers, and to examine their effect on change in motor severity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03652870 Date of registration - 29th August 2018.
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Affiliation(s)
- A Schrag
- grid.83440.3b0000000121901201Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK ,grid.437485.90000 0001 0439 3380Department of Neurology, Royal Free London NHS Foundation Trust, London, UK
| | - C Carroll
- grid.11201.330000 0001 2219 0747Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - G Duncan
- grid.39489.3f0000 0001 0388 0742NHS Lothian, Edinburgh, UK
| | - S Molloy
- grid.417895.60000 0001 0693 2181Department of Neurosciences, Imperial College Healthcare NHS Trust, London, UK
| | - L Grover
- grid.83440.3b0000000121901201Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - R Hunter
- grid.83440.3b0000000121901201Research Department of Primary Care and Population Health, University College London, London, UK
| | - R Brown
- grid.13097.3c0000 0001 2322 6764Department of Psychology, Institute of Psychiatry, King’s College London, London, UK
| | - N Freemantle
- grid.83440.3b0000000121901201Comprehensive Clinical Trials Unit, University College London, London, UK
| | - J Whipps
- PPI Representative, Plymouth, UK
| | - M. A Serfaty
- grid.83440.3b0000000121901201Division of Psychiatry, UCL, London, UK ,Priory Hospital North London, London, UK
| | - G Lewis
- grid.83440.3b0000000121901201Division of Psychiatry, UCL, London, UK
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Varela-Mato V, Godfree K, Adem A, Blake H, Bartle C, Daly G, Hassard J, Kneller R, Meyer C, Russell S, Marwaha S, Kershaw C, Newman K, Yarker J, Thomson L, Munir F. Protocol for a feasibility randomised controlled study of a multicomponent intervention to promote a sustainable return to work of workers on long-term sick leave — PROWORK: PROmoting a Sustainable and Healthy Return to WORK. Pilot Feasibility Stud 2022; 8:188. [PMID: 35986424 PMCID: PMC9389507 DOI: 10.1186/s40814-022-01143-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The cost of sickness absence has major social, psychological and financial implications for individuals and organisations. Return-to-work (RTW) interventions that support good quality communication and contact with the workplace can reduce the length of sickness absence by between 15 and 30 days. However, initiatives promoting a sustainable return to work for workers with poor mental health on long-term sickness absence across small, medium and large enterprises (SMEs and LEs) are limited. This paper describes the protocol of a pilot randomised controlled trial (RCT) to test the feasibility of implementing a RTW intervention across SMEs and LEs across all sectors.
Methods and design
A two-arm feasibility RCT with a 4-month intervention will be conducted in SMEs and LE enterprises from the Midlands region, UK. At least 8 organisations (4 controls and interventions), and at least 60 workers and/or managers, will be recruited and randomised into the intervention and control group (30 interventions, 30 controls). Workers on long-term sickness absence (LTSA) (between 8 and 50 days) and managers with a worker on LTSA will be eligible to participate. The intervention is a behavioural change programme, including a managers and workers RTW toolkit, focused on supporting sickness absence and RTW through the provision of knowledge, problem-solving, action planning, goal setting and positive communication that leads to a sustainable RTW. Organisations assigned to the control group will continue with their usual practice. Measurements of mental health, RTW, work outcomes, quality-of-life, workplace support and communication and other demographic data will be taken at baseline, 2 months and 4 months. Feasibility will be assessed based on recruitment, retention, attrition, completion of measures and intervention compliance for which specific process and research outcomes have been established. A process evaluation will explore the experiences and acceptability of the intervention components and evaluation measures. Exploratory economic evaluation will be conducted to further inform a definitive trial.
Discussion
This is a novel intervention using a worker-manager approach to promote a sustainable return to work of workers on long-term sick leave due to poor mental wellbeing. If this intervention is shown to be feasible, the outcomes will inform a larger scale randomised control trial.
Trial registration
ISRCTN90032009 (retrospectively registered, date registered 15th December 2020)
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Thomas KH, Dalili MN, López-López JA, Keeney E, Phillippo D, Munafò MR, Stevenson M, Caldwell DM, Welton NJ. Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2021; 25:1-224. [PMID: 34668482 DOI: 10.3310/hta25590] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes. OBJECTIVES To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes. DESIGN Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results. SETTING Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes. PARTICIPANTS Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes. INTERVENTIONS Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies. MAIN OUTCOME MEASURES Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events. DATA SOURCES Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019. REVIEW METHODS Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model. RESULTS Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard. LIMITATIONS Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified. CONCLUSIONS Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK. FUTURE WORK Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041302. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 59. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kyla H Thomas
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael N Dalili
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - José A López-López
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - David Phillippo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marcus R Munafò
- Faculty of Life Sciences, School of Psychological Science, University of Bristol, Bristol, UK.,MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,UK Centre for Tobacco and Alcohol Studies, University of Bristol, Bristol, UK
| | - Matt Stevenson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Deborah M Caldwell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Qian Y, Walters SJ, Jacques R, Flight L. Comprehensive review of statistical methods for analysing patient-reported outcomes (PROs) used as primary outcomes in randomised controlled trials (RCTs) published by the UK's Health Technology Assessment (HTA) journal (1997-2020). BMJ Open 2021; 11:e051673. [PMID: 34489292 PMCID: PMC8422492 DOI: 10.1136/bmjopen-2021-051673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To identify how frequently patient-reported outcomes (PROs) are used as primary and/or secondary outcomes in randomised controlled trials (RCTs) and to summarise what statistical methods are used for the analysis of PROs. DESIGN Comprehensive review. SETTING RCTs funded and published by the United Kingdom's (UK) National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme. DATA SOURCES AND ELIGIBILITY HTA reports of RCTs published between January 1997 and December 2020 were reviewed. DATA EXTRACTION Information relating to PRO use and analysis methods was extracted. PRIMARY AND SECONDARY OUTCOME MEASURES The frequency of using PROs as primary and/or secondary outcomes; statistical methods that were used for the analysis of PROs as primary outcomes. RESULTS In this review, 37.6% (114/303) of trials used PROs as primary outcomes, and 82.8% (251/303) of trials used PROs as secondary outcomes from 303 NIHR HTA reports of RCTs. In the 114 RCTs where the PRO was the primary outcome, the most used PRO was the Short-Form 36 (8/114); the most popular methods for multivariable analysis were linear mixed model (45/114), linear regression (29/114) and analysis of covariance (13/114); logistic regression was applied for binary and ordinal outcomes in 14/114 trials; and the repeated measures analysis was used in 39/114 trials. CONCLUSION The majority of trials used PROs as primary and/or secondary outcomes. Conventional methods such as linear regression are widely used, despite the potential violation of their assumptions. In recent years, there is an increasing trend of using complex models (eg, with mixed effects). Statistical methods developed to address these violations when analysing PROs, such as beta-binomial regression, are not routinely used in practice. Future research will focus on evaluating available statistical methods for the analysis of PROs.
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Affiliation(s)
- Yirui Qian
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Richard Jacques
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Hofmann SG, Curtiss J, Carpenter JK, Kind S. Effect of treatments for depression on quality of life: a meta-analysis. Cogn Behav Ther 2017; 46:265-286. [PMID: 28440699 DOI: 10.1080/16506073.2017.1304445] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the two first-line treatments for depression, but little is known about their effects on quality of life (QOL). A meta-analysis was conducted to examine changes in QOL in adults with major depressive disorder who received CBT (24 studies examining 1969 patients) or SSRI treatment (13 studies examining 4286 patients) for their depression. Moderate improvements in QOL from pre to post-treatment were observed in both CBT (Hedges' g = .63) and SSRI (Hedges' g = .79) treatments. The effect size remained stable over the course of the follow-up period for CBT. No data were available to examine follow-ups in the SSRI group. QOL effect sizes decreased linearly with publication year, and greater improvements in depression were significantly associated with greater improvements in QOL for CBT, but not for SSRIs. CBT and SSRIs for depression were both associated with moderate improvements in QOL, but are possibly caused by different mechanisms.
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Affiliation(s)
- Stefan G Hofmann
- a Department of Psychological and Brain Sciences , Boston University , 648 Beacon Street, 6th Floor, Boston , MA 02215 , USA
| | - Joshua Curtiss
- a Department of Psychological and Brain Sciences , Boston University , 648 Beacon Street, 6th Floor, Boston , MA 02215 , USA
| | - Joseph K Carpenter
- a Department of Psychological and Brain Sciences , Boston University , 648 Beacon Street, 6th Floor, Boston , MA 02215 , USA
| | - Shelley Kind
- a Department of Psychological and Brain Sciences , Boston University , 648 Beacon Street, 6th Floor, Boston , MA 02215 , USA.,b Psychology Department , Suffolk University , 73 Tremont Street, 8th Floor, Boston , MA 02108 , USA
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9
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Rao TSS, Manohar JS, Raman R, Darshan MS, Tandon A, Karthik KN, Saraswathi N, Das K, Harsha GT, Kunkeri SP, Andrade C. The prospective, 24-week assessment of cost-efficacy of and compliance to antidepressant medications in a rural setting (PACECAR) study. Indian J Psychiatry 2017; 59:157-163. [PMID: 28827861 PMCID: PMC5547855 DOI: 10.4103/psychiatry.indianjpsychiatry_202_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Anxiety and depression are common mental health disorders that are responsible for considerable societal burden. There are no data on cost-efficacy and medication compliance related to the treatment of these disorders in rural India. MATERIALS AND METHODS All consenting adults (n = 455) diagnosed with generalized anxiety or (unipolar) depressive disorders in Suttur village, Karnataka, were treated with open-label fluoxetine (20-60 mg/day), sertraline (50-150 mg/day), escitalopram (10-20 mg/day), desvenlafaxine (50-150 mg/day), duloxetine (30-90 mg/day), amitriptyline (75-150 mg/day), or clomipramine (75-150 mg/day) in a structured, monotherapy dosing plan. The study was nonrandomized and otherwise naturalistic. Patients were followed up every 4 weeks for 24 weeks. Study discontinuation was defined as medication noncompliance for 3 or more days or withdrawal due to treatment nonresponse. RESULTS There was substantial discontinuation (34.5%) in the first 4 weeks; 55.4% had discontinued by 12 weeks. Subsequently, only 11.2% discontinued treatment. Only 33.4% of the subjects tolerated the treatment, responded to it, and remained compliant for 24 weeks. Such successful completion was highest for escitalopram and desvenlafaxine (46%-47%) and lowest for clomipramine and amitriptyline (10%-14%). Adverse events were the most common reason for noncompliance with clomipramine and amitriptyline (45%-46%); the experience of sufficient improvement was the most common reason for noncompliance with the remaining drugs (28%-49%). Whereas the average cost of efficacious treatment for a continuous period of 24 weeks was lowest for fluoxetine, an examination of the cost-efficacy tradeoff suggested maximum advantage for escitalopram, sertraline, and desvenlafaxine. The cost-efficacy profile for amitriptyline and clomipramine was poor. CONCLUSIONS Reasons for noncompliance vary by drug class and need to be considered when prescribing antidepressant drugs. Escitalopram, sertraline, and desvenlafaxine perhaps have the most favorable 24-week cost-efficacy profile; tricyclics are poorly tolerated. Rural subjects need to be educated that treatment must be continued even after improvement is established.
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Affiliation(s)
- T. S. Sathyanarayana Rao
- Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India
| | - J Shivanand Manohar
- Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India
| | - Rajesh Raman
- Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India
| | - M. S. Darshan
- Formerly Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, India
| | - Abhinav Tandon
- Formerly Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, India
| | - K. N. Karthik
- Formerly Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, India
| | - N Saraswathi
- Formerly Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, India
| | - Keya Das
- Formerly Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, India
| | - G. T. Harsha
- Formerly Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, India
| | - Swetha Patil Kunkeri
- Formerly Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, India
| | - Chittaranjan Andrade
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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10
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Celik C, Ozdemir B, Ozmenler KN, Yelboga Z, Balikci A, Oznur T, Doruk A, Bozkurt A. Efficacy of Paroxetine and Amitriptyline in Posttraumatic Stress Disorder: An Open-label Comparative Study. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20110627111141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Cemil Celik
- Gülhane Askeri Tıp Fakültesi Psikiyatri Anabilim Dalı, Askeri Psikoloji ve Harp Psikiyatrisi Bilim Dalı, Ankara-Turkey
| | - Barbaros Ozdemir
- Gülhane Askeri Tıp Fakültesi Psikiyatri Anabilim Dalı, Askeri Psikoloji ve Harp Psikiyatrisi Bilim Dalı, Ankara-Turkey
| | - Kamil Nahit Ozmenler
- Gülhane Askeri Tıp Fakültesi Psikiyatri Anabilim Dalı, Askeri Psikoloji ve Harp Psikiyatrisi Bilim Dalı, Ankara-Turkey
| | | | | | | | - Ali Doruk
- Gülhane Askeri Tıp Fakültesi, Psikiyatri Anabilim Dalı, Ankara-Turkey
| | - Ali Bozkurt
- Gülhane Askeri Tıp Fakültesi, Psikiyatri Anabilim Dalı, Ankara-Turkey
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11
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Beard E, Shahab L, Cummings DM, Michie S, West R. New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline? CNS Drugs 2016; 30:951-83. [PMID: 27421270 DOI: 10.1007/s40263-016-0362-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A wide range of support is available to help smokers to quit and to aid attempts at harm reduction, including three first-line smoking cessation medications: nicotine replacement therapy, varenicline and bupropion. Despite the efficacy of these, there is a continual need to diversify the range of medications so that the needs of tobacco users are met. This paper compares the first-line smoking cessation medications with (1) two variants of these existing products: new galenic formulations of varenicline and novel nicotine delivery devices; and (2) 24 alternative products: cytisine (novel outside Central and Eastern Europe), nortriptyline, other tricyclic antidepressants, electronic cigarettes, clonidine (an anxiolytic), other anxiolytics (e.g. buspirone), selective serotonin reuptake inhibitors, supplements (e.g. St John's wort), silver acetate, Nicobrevin, modafinil, venlafaxine, monoamine oxidase inhibitors (MAOIs), opioid antagonists, nicotinic acetylcholine receptor (nAChR) antagonists, glucose tablets, selective cannabinoid type 1 receptor antagonists, nicotine vaccines, drugs that affect gamma-aminobutyric acid (GABA) transmission, drugs that affect N-methyl-D-aspartate (NMDA) receptors, dopamine agonists (e.g. levodopa), pioglitazone (Actos; OMS405), noradrenaline reuptake inhibitors and the weight management drug lorcaserin. Six 'ESCUSE' criteria-relative efficacy, relative safety, relative cost, relative use (overall impact of effective medication use), relative scope (ability to serve new groups of patients) and relative ease of use-are used. Many of these products are in the early stages of clinical trials; however, cytisine looks most promising in having established efficacy and safety with low cost. Electronic cigarettes have become very popular, appear to be efficacious and are safer than smoking, but issues of continued dependence and possible harms need to be considered.
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Affiliation(s)
- Emma Beard
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK.
- Department of Clinical, Educational and Health Psychology, University College London, London, WC1E 6BP, UK.
| | - Lion Shahab
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK
| | - Damian M Cummings
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, WC1E 6BT, UK
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, London, WC1E 6BP, UK
| | - Robert West
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK
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12
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Littlewood E, Duarte A, Hewitt C, Knowles S, Palmer S, Walker S, Andersen P, Araya R, Barkham M, Bower P, Brabyn S, Brierley G, Cooper C, Gask L, Kessler D, Lester H, Lovell K, Muhammad U, Parry G, Richards DA, Richardson R, Tallon D, Tharmanathan P, White D, Gilbody S. A randomised controlled trial of computerised cognitive behaviour therapy for the treatment of depression in primary care: the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial. Health Technol Assess 2016; 19:viii, xxi-171. [PMID: 26685904 DOI: 10.3310/hta191010] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Computerised cognitive behaviour therapy (cCBT) has been developed as an efficient form of therapy delivery with the potential to enhance access to psychological care. Independent research is needed which examines both the clinical effectiveness and cost-effectiveness of cCBT over the short and longer term. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of cCBT as an adjunct to usual general practitioner (GP) care against usual GP care alone, for a free-to-use cCBT program (MoodGYM; National Institute for Mental Health Research, Australian National University, Canberra, Australia) and a commercial pay-to-use cCBT program (Beating the Blues(®); Ultrasis, London, UK) for adults with depression, and to determine the acceptability of cCBT and the experiences of users. DESIGN A pragmatic, multicentre, three-armed, parallel, randomised controlled trial (RCT) with concurrent economic and qualitative evaluations. Simple randomisation was used. Participants and researchers were not blind to treatment allocation. SETTING Primary care in England. PARTICIPANTS Adults with depression who scored ≥ 10 on the Patient Health Questionnaire-9 (PHQ-9). INTERVENTIONS Participants who were randomised to either of the two intervention groups received cCBT (Beating the Blues or MoodGYM) in addition to usual GP care. Participants who were randomised to the control group were offered usual GP care. MAIN OUTCOME MEASURES The primary outcome was depression at 4 months (PHQ-9). Secondary outcomes were depression at 12 and 24 months; measures of mental health and health-related quality of life at 4, 12 and 24 months; treatment preference; and the acceptability of cCBT and experiences of users. RESULTS Clinical effectiveness: 210 patients were randomised to Beating the Blues, 242 patients were randomised to MoodGYM and 239 patients were randomised to usual GP care (total 691). There was no difference in the primary outcome (depression measured at 4 months) either between Beating the Blues and usual GP care [odds ratio (OR) 1.19, 95% confidence interval (CI) 0.75 to 1.88] or between MoodGYM and usual GP care (OR 0.98, 95% CI 0.62 to 1.56). There was no overall difference across all time points for either intervention compared with usual GP care in a mixed model (Beating the Blues versus usual GP care, p = 0.96; and MoodGYM versus usual GP care, p = 0.11). However, a small but statistically significant difference between MoodGYM and usual GP care at 12 months was found (OR 0.56, 95% CI 0.34 to 0.93). Free-to-use cCBT (MoodGYM) was not inferior to pay-to-use cCBT (Beating the Blues) (OR 0.91, 90% CI 0.62 to 1.34; p = 0.69). There were no consistent benefits of either intervention when secondary outcomes were examined. There were no serious adverse events thought likely to be related to the trial intervention. Despite the provision of regular technical telephone support, there was low uptake of the cCBT programs. Cost-effectiveness: cost-effectiveness analyses suggest that neither Beating the Blues nor MoodGYM appeared cost-effective compared with usual GP care alone. Qualitative evaluation: participants were often demotivated to access the computer programs, by reason of depression. Some expressed the view that a greater level of therapeutic input would be needed to promote engagement. CONCLUSIONS The benefits that have previously been observed in developer-led trials were not found in this large pragmatic RCT. The benefits of cCBT when added to routine primary care were minimal, and uptake of this mode of therapy was relatively low. There remains a clinical and economic need for effective low-intensity psychological treatments for depression with improved patient engagement. TRIAL REGISTRATION This trial is registered as ISRCTN91947481. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Ana Duarte
- Centre for Health Economics, University of York, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarah Knowles
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.,National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK (previously National Primary Care Research and Development Centre, University of Manchester, Manchester, UK)
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Phil Andersen
- Department of Health Sciences, University of York, York, UK
| | - Ricardo Araya
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Barkham
- Centre for Psychological Services Research, University of Sheffield, Sheffield, UK
| | - Peter Bower
- National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK (previously National Primary Care Research and Development Centre, University of Manchester, Manchester, UK)
| | - Sally Brabyn
- Department of Health Sciences, University of York, York, UK
| | - Gwen Brierley
- Department of Health Sciences, University of York, York, UK.,Medical Research Council (MRC) Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Linda Gask
- National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK (previously National Primary Care Research and Development Centre, University of Manchester, Manchester, UK)
| | - David Kessler
- Academic Unit of Primary Health Care, University of Bristol, Bristol, UK
| | - Helen Lester
- National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK (previously National Primary Care Research and Development Centre, University of Manchester, Manchester, UK).,Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Usman Muhammad
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Glenys Parry
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - David A Richards
- Department of Health Sciences, University of York, York, UK.,University of Exeter Medical School, University of Exeter, Exeter, UK
| | | | - Debbie Tallon
- School of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Puvan Tharmanathan
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David White
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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13
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Helvik AS, Corazzini K, Selbæk G, Bjørkløf GH, Laks J, Šaltytė Benth J, Østbye T, Engedal K. Health-related quality of life in older depressed psychogeriatric patients: one year follow-up. BMC Geriatr 2016; 16:131. [PMID: 27388445 PMCID: PMC4936227 DOI: 10.1186/s12877-016-0310-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 06/17/2016] [Indexed: 11/16/2022] Open
Abstract
Background Knowledge about long-term change in health related quality of life (HQoL) among older adults after hospitalization for treatment of depression has clinical relevance. The aim was firstly to describe the change of HQoL one year after admission for treatment of depression, secondly to explore if improved HQoL was associated with remission of depression at follow-up and lastly to study how HQoL in patients with remission from depression were compared to a reference group of older persons without depression. Method This study had the one year follow-up information of 108 older patients (≥60 years), all hospitalized for depression at baseline, and a reference sample of 106 community-living older adults (≥60 years) without depression. HQoL was measured using the EuroQol Group’s EQ-5D Index and a visual analog scale (EQ-VAS). Depression and remission were diagnosed according to ICD-10. Socio-demographic variables (age, gender, and education), depressive symptom score (Montgomery-Aasberg Depression Rating Scale), cognitive functioning (Mini Mental State Examination scale), instrumental activities of daily living (the Lawton and Brody’s Instrumental Activities of Daily Living Scale), and poor general physical health (General Medical Health Rating) were included as covariates. Results HQoL had improved at follow-up for the total group of depressed patients, as indicated by better scores on the EQ-5D Index and EQ-VAS. In the multivariate linear regression model, improved EQ-5D Index and EQ-VAS was significantly better in those with remission of depression and those with better baseline physical health. In adjusted analyses, the HQoL in patients with remission from depression at follow-up did not differ from the HQoL in a reference group without depression. Conclusion Older hospital patients with depression who experienced remission one year after admission gained HQoL and their HQoL was comparable with the HQoL in a reference group of older adults without depression when adjusting for differences in socio-demographics and health conditions.
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Affiliation(s)
- Anne-Sofie Helvik
- Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway. .,St. Olav's University Hospital, Trondheim, Norway. .,Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway.
| | | | - Geir Selbæk
- Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway.,Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway.,Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Guro Hanevold Bjørkløf
- Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway
| | - Jerson Laks
- Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Post Graduation Program in Translational Medicine, Universidade do Grande Rio (Unigranrio), Rio de Janeiro, Brazil
| | - Jūratė Šaltytė Benth
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway.,Institute of Clinical Medicine, Ahus Campus, University of Oslo, Oslo, Norway.,Research Centre, HØKH, Akershus University Hospital, Lørenskog, Norway
| | | | - Knut Engedal
- Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway
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14
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Claxton K, Martin S, Soares M, Rice N, Spackman E, Hinde S, Devlin N, Smith PC, Sculpher M. Methods for the estimation of the National Institute for Health and Care Excellence cost-effectiveness threshold. Health Technol Assess 2015; 19:1-503, v-vi. [PMID: 25692211 DOI: 10.3310/hta19140] [Citation(s) in RCA: 483] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cost-effectiveness analysis involves the comparison of the incremental cost-effectiveness ratio of a new technology, which is more costly than existing alternatives, with the cost-effectiveness threshold. This indicates whether or not the health expected to be gained from its use exceeds the health expected to be lost elsewhere as other health-care activities are displaced. The threshold therefore represents the additional cost that has to be imposed on the system to forgo 1 quality-adjusted life-year (QALY) of health through displacement. There are no empirical estimates of the cost-effectiveness threshold used by the National Institute for Health and Care Excellence. OBJECTIVES (1) To provide a conceptual framework to define the cost-effectiveness threshold and to provide the basis for its empirical estimation. (2) Using programme budgeting data for the English NHS, to estimate the relationship between changes in overall NHS expenditure and changes in mortality. (3) To extend this mortality measure of the health effects of a change in expenditure to life-years and to QALYs by estimating the quality-of-life (QoL) associated with effects on years of life and the additional direct impact on QoL itself. (4) To present the best estimate of the cost-effectiveness threshold for policy purposes. METHODS Earlier econometric analysis estimated the relationship between differences in primary care trust (PCT) spending, across programme budget categories (PBCs), and associated disease-specific mortality. This research is extended in several ways including estimating the impact of marginal increases or decreases in overall NHS expenditure on spending in each of the 23 PBCs. Further stages of work link the econometrics to broader health effects in terms of QALYs. RESULTS The most relevant 'central' threshold is estimated to be £12,936 per QALY (2008 expenditure, 2008-10 mortality). Uncertainty analysis indicates that the probability that the threshold is < £20,000 per QALY is 0.89 and the probability that it is < £30,000 per QALY is 0.97. Additional 'structural' uncertainty suggests, on balance, that the central or best estimate is, if anything, likely to be an overestimate. The health effects of changes in expenditure are greater when PCTs are under more financial pressure and are more likely to be disinvesting than investing. This indicates that the central estimate of the threshold is likely to be an overestimate for all technologies which impose net costs on the NHS and the appropriate threshold to apply should be lower for technologies which have a greater impact on NHS costs. LIMITATIONS The central estimate is based on identifying a preferred analysis at each stage based on the analysis that made the best use of available information, whether or not the assumptions required appeared more reasonable than the other alternatives available, and which provided a more complete picture of the likely health effects of a change in expenditure. However, the limitation of currently available data means that there is substantial uncertainty associated with the estimate of the overall threshold. CONCLUSIONS The methods go some way to providing an empirical estimate of the scale of opportunity costs the NHS faces when considering whether or not the health benefits associated with new technologies are greater than the health that is likely to be lost elsewhere in the NHS. Priorities for future research include estimating the threshold for subsequent waves of expenditure and outcome data, for example by utilising expenditure and outcomes available at the level of Clinical Commissioning Groups as well as additional data collected on QoL and updated estimates of incidence (by age and gender) and duration of disease. Nonetheless, the study also starts to make the other NHS patients, who ultimately bear the opportunity costs of such decisions, less abstract and more 'known' in social decisions. FUNDING The National Institute for Health Research-Medical Research Council Methodology Research Programme.
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Affiliation(s)
- Karl Claxton
- Centre for Health Economics, University of York, York, UK
| | - Steve Martin
- Department of Economics and Related Studies, University of York, York, UK
| | - Marta Soares
- Centre for Health Economics, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Eldon Spackman
- Centre for Health Economics, University of York, York, UK
| | | | | | - Peter C Smith
- Imperial College Business School and Centre for Health Policy, Imperial College London, London, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
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15
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Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, Barkham M, Bower P, Cooper C, Gask L, Kessler D, Lester H, Lovell K, Parry G, Richards DA, Andersen P, Brabyn S, Knowles S, Shepherd C, Tallon D, White D. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ 2015; 351:h5627. [PMID: 26559241 PMCID: PMC4641883 DOI: 10.1136/bmj.h5627] [Citation(s) in RCA: 250] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 12/04/2022]
Abstract
STUDY QUESTION How effective is supported computerised cognitive behaviour therapy (cCBT) as an adjunct to usual primary care for adults with depression? METHODS This was a pragmatic, multicentre, three arm, parallel randomised controlled trial with simple randomisation. Treatment allocation was not blinded. Participants were adults with symptoms of depression (score ≥ 10 on nine item patient health questionnaire, PHQ-9) who were randomised to receive a commercially produced cCBT programme ("Beating the Blues") or a free to use cCBT programme (MoodGYM) in addition to usual GP care. Participants were supported and encouraged to complete the programme via weekly telephone calls. Control participants were offered usual GP care, with no constraints on the range of treatments that could be accessed. The primary outcome was severity of depression assessed with the PHQ-9 at four months. Secondary outcomes included health related quality of life (measured by SF-36) and psychological wellbeing (measured by CORE-OM) at four, 12, and 24 months and depression at 12 and 24 months. STUDY ANSWER AND LIMITATIONS Participants offered commercial or free to use cCBT experienced no additional improvement in depression compared with usual GP care at four months (odds ratio 1.19 (95% confidence interval 0.75 to 1.88) for Beating the Blues v usual GP care; 0.98 (0.62 to 1.56) for MoodGYM v usual GP care). There was no evidence of an overall difference between either programme compared with usual GP care (0.99 (0.57 to 1.70) and 0.68 (0.42 to 1.10), respectively) at any time point. Commercially provided cCBT conferred no additional benefit over free to use cCBT or usual GP care at any follow-up point. Uptake and use of cCBT was low, despite regular telephone support. Nearly a quarter of participants (24%) had dropped out by four months. The study did not have enough power to detect small differences so these cannot be ruled out. Findings cannot be generalised to cCBT offered with a much higher level of guidance and support. WHAT THIS STUDY ADDS Supported cCBT does not substantially improve depression outcomes compared with usual GP care alone. In this study, neither a commercially available nor free to use computerised CBT intervention was superior to usual GP care. FUNDING, COMPETING INTERESTS, DATA SHARING Commissioned and funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project No 06/43/05). The authors have no competing interests. Requests for patient level data will be considered by the REEACT trial management groupTrial registration Current Controlled Trials ISRCTN91947481.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | | | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Gwen Brierley
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge CB2 0QQ, UK
| | - Puvan Tharmanathan
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Ricardo Araya
- Department of Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Michael Barkham
- Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield S10 2TP, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Linda Gask
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
| | - David Kessler
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol BS8 2BN, UK
| | - Helen Lester
- Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester M13 9PL, UK
| | - Glenys Parry
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - David A Richards
- University of Exeter Medical School, University of Exeter, Exeter EX1 2LU, UK
| | - Phil Andersen
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Sarah Knowles
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
| | - Charles Shepherd
- Faculty of Health and Social Care, University of Hull, Hull HU6 7RX, UK
| | - Debbie Tallon
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol BS8 2BN, UK
| | - David White
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
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Cleare A, Pariante CM, Young AH, Anderson IM, Christmas D, Cowen PJ, Dickens C, Ferrier IN, Geddes J, Gilbody S, Haddad PM, Katona C, Lewis G, Malizia A, McAllister-Williams RH, Ramchandani P, Scott J, Taylor D, Uher R. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol 2015; 29:459-525. [PMID: 25969470 DOI: 10.1177/0269881115581093] [Citation(s) in RCA: 414] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.
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Affiliation(s)
- Anthony Cleare
- Professor of Psychopharmacology & Affective Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - C M Pariante
- Professor of Biological Psychiatry, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - A H Young
- Professor of Psychiatry and Chair of Mood Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - I M Anderson
- Professor and Honorary Consultant Psychiatrist, University of Manchester Department of Psychiatry, University of Manchester, Manchester, UK
| | - D Christmas
- Consultant Psychiatrist, Advanced Interventions Service, Ninewells Hospital & Medical School, Dundee, UK
| | - P J Cowen
- Professor of Psychopharmacology, Psychopharmacology Research Unit, Neurosciences Building, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - C Dickens
- Professor of Psychological Medicine, University of Exeter Medical School and Devon Partnership Trust, Exeter, UK
| | - I N Ferrier
- Professor of Psychiatry, Honorary Consultant Psychiatrist, School of Neurology, Neurobiology & Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - J Geddes
- Head, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - S Gilbody
- Director of the Mental Health and Addictions Research Group (MHARG), The Hull York Medical School, Department of Health Sciences, University of York, York, UK
| | - P M Haddad
- Consultant Psychiatrist, Cromwell House, Greater Manchester West Mental Health NHS Foundation Trust, Salford, UK
| | - C Katona
- Division of Psychiatry, University College London, London, UK
| | - G Lewis
- Division of Psychiatry, University College London, London, UK
| | - A Malizia
- Consultant in Neuropsychopharmacology and Neuromodulation, North Bristol NHS Trust, Rosa Burden Centre, Southmead Hospital, Bristol, UK
| | - R H McAllister-Williams
- Reader in Clinical Psychopharmacology, Institute of Neuroscience, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - P Ramchandani
- Reader in Child and Adolescent Psychiatry, Centre for Mental Health, Imperial College London, London, UK
| | - J Scott
- Professor of Psychological Medicine, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - D Taylor
- Professor of Psychopharmacology, King's College London, London, UK
| | - R Uher
- Associate Professor, Canada Research Chair in Early Interventions, Dalhousie University, Department of Psychiatry, Halifax, NS, Canada
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Depression and pain: an appraisal of cost effectiveness and cost utility of antidepressants. J Psychiatr Res 2015; 63:123-31. [PMID: 25727051 DOI: 10.1016/j.jpsychires.2015.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 01/10/2015] [Accepted: 01/31/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although depression and chronic pain frequently co-occur, there is a lack of clarity in the literature regarding the cost-effectiveness and cost-utility of antidepressants in the presence of these two conditions. From the perspective of healthcare provider, the current study aims to compare the cost-effectiveness and cost-utility of antidepressants in a national cohort of depressed patients with and without comorbid pain conditions. METHODS Adult patients prescribed with antidepressants for depression were identified from the National Health Insurance Research Database in Taiwan (n=96,501). By using remission as effectiveness measure and quality-adjusted life years (QALYs) as utility measure, the cost-effectiveness and cost-utility were compared across selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), as well as by the presence of comorbid painful physical symptoms (PPS). RESULTS SSRIs dominated SNRIs in both the cost-effectiveness and cost-utility regardless of comorbid PPS. In comparison with TCAs, SSRIs were likely to be the cost-effective option for patients without PPS. In patients with PPS, the cost-utility advantage for SSRIs over TCAs varied with threshold willingness-to-pay levels. Comorbid PPS may be considered an effect modifier of the cost-utility comparisons between SSRIs and TCAs. CONCLUSIONS For depressed patients without PPS, SSRIs are likely to be cost-effective in improving remission rates and QALYs compared to TCAs and SNRIs. However, to improve cost-utility in those with comorbid PPS, people need to choose between SSRIs and TCAs according to threshold willingness-to-pay levels. Future research is warranted to clarify the impacts of different pain conditions on the economic evaluations of pharmacological treatments in patients with depression.
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Bedson E, Bell D, Carr D, Carter B, Hughes D, Jorgensen A, Lewis H, Lloyd K, McCaddon A, Moat S, Pink J, Pirmohamed M, Roberts S, Russell I, Sylvestre Y, Tranter R, Whitaker R, Wilkinson C, Williams N. Folate Augmentation of Treatment--Evaluation for Depression (FolATED): randomised trial and economic evaluation. Health Technol Assess 2015; 18:vii-viii, 1-159. [PMID: 25052890 DOI: 10.3310/hta18480] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Folate deficiency is associated with depression. Despite the biological plausibility of a causal link, the evidence that adding folate enhances antidepressant treatment is weak. OBJECTIVES (1) Estimate the clinical effectiveness and cost-effectiveness of folic acid as adjunct to antidepressant medication (ADM). (2) Explore whether baseline folate and homocysteine predict response to treatment. (3) Investigate whether response to treatment depends on genetic polymorphisms related to folate metabolism. DESIGN FolATED (Folate Augmentation of Treatment - Evaluation for Depression) was a double-blind and placebo-controlled, but otherwise pragmatic, randomised trial including cost-utility analysis. To yield 80% power of detecting standardised difference on the Beck Depression Inventory version 2 (BDI-II) of 0.3 between groups (a 'small' effect), FolATED trialists sought to analyse 358 participants. To allow for an estimated loss of 21% of participants over three time points, we planned to randomise 453. SETTINGS Clinical - Three centres in Wales - North East Wales, North West Wales and Swansea. Trial management - North Wales Organisation for Randomised Trials in Health in Bangor University. Biochemical analysis - University Hospital of Wales, Cardiff. Genetic analysis - University of Liverpool. PARTICIPANTS Four hundred and seventy-five adult patients presenting to primary or secondary care with confirmed moderate to severe depression for which they were taking or about to start ADM, and able to consent and complete assessments, but not (1) folate deficient, vitamin B12 deficient, or taking folic acid or anticonvulsants; (2) misusing drugs or alcohol, or suffering from psychosis, bipolar disorder, malignancy or other unstable or terminal illness; (3) (planning to become) pregnant; or (4) participating in other clinical research. INTERVENTIONS Once a day for 12 weeks experimental participants added 5 mg of folic acid to their ADM, and control participants added an indistinguishable placebo. All participants followed pragmatic management plans initiated by a trial psychiatrist and maintained by their general medical practitioners. MAIN OUTCOME MEASURES Assessed at baseline, and 4, 12 and 25 weeks thereafter, and analysed by 'area under curve' (main); by analysis of covariance at each time point (secondary); and by multi-level repeated measures (sensitivity analysis): Mental health - BDI-II (primary), Clinical Global Impression (CGI), Montgomery-Åsberg Depression Rating Scale (MADRS), UKU side effects scale, and Mini International Neuropsychiatric Interview (MINI) suicidality subscale; General health - UK 12-item Short Form Health Survey (SF-12), European Quality of Life scale - 5 Dimensions (EQ-5D); Biochemistry - serum folate, B12, homocysteine; Adherence - Morisky Questionnaire; Economics - resource use. RESULTS Folic acid did not significantly improve any of these measures. For example it gained a mean of just 2.9 quality-adjusted life-days [95% confidence interval (CI) from -12.7 to 7.0 days] and saved a mean of just £48 (95% CI from -£292 to £389). In contrast it significantly reduced mental health scores on the SF-12 by 3.0% (95% CI from -5.2% to -0.8%). CONCLUSIONS The FolATED trial generated no evidence that folic acid was clinically effective or cost-effective in augmenting ADM. This negative finding is consistent with improving understanding of the one-carbon folate pathway suggesting that methylfolate is a better candidate for augmenting ADM. Hence the findings of FolATED undermine treatment guidelines that advocate folic acid for treating depression, and suggest future trials of methylfolate to augment ADM. TRIAL REGISTRATION Current Controlled Trials ISRCTN37558856. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 48. See the HTA programme website for further project information.
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Affiliation(s)
- Emma Bedson
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Diana Bell
- Ysbyty Gwynedd, Betsi Cadwalladr University Health Board, Bangor, UK
| | - Daniel Carr
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Ben Carter
- School of Medicine, Cardiff University, Cardiff, UK
| | - Dyfrig Hughes
- Centre for Economics and Policy in Health, Bangor University, Bangor, UK
| | - Andrea Jorgensen
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Helen Lewis
- Department of Health Sciences, University of York, York, UK
| | - Keith Lloyd
- College of Medicine, Swansea University, Swansea, UK
| | - Andrew McCaddon
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Stuart Moat
- Medical Biochemistry & Immunology, University Hospital of Wales, Cardiff, UK
| | - Joshua Pink
- Centre for Economics and Policy in Health, Bangor University, Bangor, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Seren Roberts
- Centre for Mental Health & Society, Bangor University, Bangor, UK
| | - Ian Russell
- College of Medicine, Swansea University, Swansea, UK
| | | | - Richard Tranter
- Department of Psychological Medicine, University of Otago, Christchurch, NZ
| | - Rhiannon Whitaker
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Nefyn Williams
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
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Ridyard CH, Hughes DA. Taxonomy for methods of resource use measurement. HEALTH ECONOMICS 2015; 24:372-8. [PMID: 24442966 DOI: 10.1002/hec.3029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 09/12/2013] [Accepted: 12/04/2013] [Indexed: 05/21/2023]
Abstract
Resource use measures, including forms, diaries and questionnaires, are ubiquitous in trial-based economic evaluations in the UK. However, there are concerns about the accuracy of how they are described, which limits the transparency of reporting. We developed a simple and structured taxonomy for methods of resource use measurement by examining 94 resource use measures (RUMs) employed within clinical trials, conducting a descriptive synthesis of the extracted data and soliciting wider opinion during a period of consultation. The reporting of RUMs was found to be varied and inconsistent. Our new taxonomy, which considered the views of 20 consultees, requires that RUMs are reported with a description of the following: (i) the source of data (patient; patient proxy, e.g. carer, parent or guardian; observation of contemporary events; medical records; or other databases); (ii) who completes the RUM (patient or their proxy, and researcher or health care professional); (iii) how it is administered (to self [the patient], face to face or telephone); (iv) how it is recorded (form, questionnaire, log or diary); and (v) medium of recording (e.g. paper or electronically). Based on the present analysis, we have developed a taxonomy for RUMs that should result in data collection methods being described more accurately.
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Affiliation(s)
- Colin H Ridyard
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Wales, UK
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Pharmacological treatment of depression with and without headache disorders: an appraisal of cost effectiveness and cost utility of antidepressants. J Affect Disord 2015; 170:255-65. [PMID: 25261631 DOI: 10.1016/j.jad.2014.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/28/2014] [Accepted: 08/25/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Depression and headache are highly prevalent in clinical settings. The co-occurrence of headache may impact choice of antidepressants, healthcare utilisation, and outcomes in patients with depression. The current study aims to examine the cost-effectiveness and cost-utility of different antidepressants for treating patients with depression and comorbid headache disorders. METHODS Adult patients prescribed with antidepressants for depression (n=96,501) were identified from the National Health Insurance Research Database in Taiwan. A cost-effectiveness and cost-utility analysis was conducted comparing selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), and by the presence of comorbid headache disorders and other pain conditions. RESULTS In this study, SSRIs dominated SNRIs in both cost-effectiveness and cost-utility. As revealed in the cost-effectiveness acceptability curves, TCAs were likely to have a cost-utility advantage compared to SSRIs and SNRIs in improving quality-adjusted life years (QALYs) for patients with comorbid headache; SSRIs remained as the most cost-effective option for patients with other pain conditions. LIMITATIONS Limitations include the use of proxy definition of remission as effectiveness measure and the adoption of utility values from previous studies. CONCLUSIONS Given a pre-determined willingness-to-pay level, TCAs can be considered as a cost-effective option to improve QALYs for depressed patients with headache disorders. Future research is needed to further clarify factors influencing the cost-effectiveness and cost-utility of pharmacological treatments in depressed patients with specific pain conditions.
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Köhler S, Unger T, Hoffmann S, Mackert A, Ross B, Fydrich T. The relationship of health-related quality of life and treatment outcome during inpatient treatment of depression. Qual Life Res 2014; 24:641-9. [PMID: 25240747 DOI: 10.1007/s11136-014-0811-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2014] [Indexed: 12/13/2022]
Abstract
PURPOSE Health-related quality of life (HRQoL) is important for long-term social functioning. It is considerably reduced in patients with depression. We studied the impact of HRQoL on treatment outcome in patients with unipolar depression. Furthermore, we analysed factors associated with HRQoL in inpatients with unipolar depression. METHODS One hundred and eighty patients suffering from major depressive disorder were evaluated during their inpatient treatment by assessing admission and discharge depression severity and their HRQoL, using the Medical Outcomes Study 12-item Short Form (SF-12). Baseline and treatment variables associated with HRQoL were examined by regression analysis. Primary outcome measures were the Hamilton Rating Scale and the Beck Depression Inventory. RESULTS HRQoL improved significantly during inpatient treatment. Lower HRQoL outcomes were strongly associated with higher age, somatic comorbidities, a recurrent depressive disorder and stronger depressive symptoms at admission. Additionally, patients with a complex treatment situation (high number of medications, antidepressant switch) showed stronger impairment of HRQoL. Personality disorders and additional psychotherapy did not predict HRQoL. CONCLUSION The inpatient treatment resulted in an increase of the SF-12 scores, although to a lower extent than depressive symptoms. Several factors negatively influence HRQoL, such as the presence of somatic and axis I psychiatric comorbiditites and a recurrent or severe depressive episode. Targeting somatic comorbidities in patients with unipolar depression seem to play an important role for HRQoL.
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Affiliation(s)
- Stephan Köhler
- Department of Psychiatry and Psychotherapy, Kliniken im Theodor-Wenzel-Werk, Berlin, Germany,
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Hunter RM, Nazareth I, Morris S, King M. Modelling the cost-effectiveness of preventing major depression in general practice patients. Psychol Med 2014; 44:1381-90. [PMID: 23947797 PMCID: PMC3967840 DOI: 10.1017/s0033291713002067] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 07/02/2013] [Accepted: 07/21/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The prevention of depression is a key public health policy priority. PredictD is the first risk algorithm for the prediction of the onset of major depression. Our aim in this study was to model the cost-effectiveness of PredictD in depression prevention in general practice (GP). METHOD A decision analytical model was developed to determine the cost-effectiveness of two approaches, each of which was compared to treatment as usual (TAU) over 12 months: (1) the PredictD risk algorithm plus a low-intensity depression prevention programme; and (2) a universal prevention programme in which there was no initial identification of those at risk. The model simulates the incidence of depression and disease progression over 12 months and calculates the net monetary benefit (NMB) from the National Health Service (NHS) perspective. RESULTS Providing patients with PredictD and a depression prevention programme prevented 15 (17%) cases of depression in a cohort of 1000 patients over 12 months and had the highest probability of being the optimal choice at a willingness to pay (WTP) of £20,000 for a quality-adjusted life year (QALY). Universal prevention was strongly dominated by PredictD plus a depression prevention programme in that universal prevention resulted in less QALYs than PredictD plus prevention for a greater cost. CONCLUSIONS Using PredictD to identify primary-care patients at high risk of depression and providing them with a low-intensity prevention programme is potentially cost-effective at a WTP of £20,000 per QALY.
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Affiliation(s)
- R. M. Hunter
- Department of Primary Care and Population Sciences, University College London Medical School, UK
| | - I. Nazareth
- Department of Primary Care and Population Sciences, University College London Medical School, UK
| | - S. Morris
- Department of Applied Health Research, University College London Medical School, UK
| | - M. King
- Department of Mental Health Sciences, University College London Medical School, UK
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Mohiuddin S, Payne K. Utility Values for Adults with Unipolar Depression: Systematic Review and Meta-Analysis. Med Decis Making 2014; 34:666-85. [PMID: 24695961 DOI: 10.1177/0272989x14524990] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 01/28/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND Unipolar depression is a mental illness with a substantial health-related and economic burden. Health interventions for depression predominately focus on improving sufferers' health-related quality of life (HRQoL). Utility is a measure of HRQoL that is required for use in model-based cost-utility analyses to assess the added value of health interventions. This review aimed to identify, summarize, and where feasible, synthesize published utilities for unipolar depression. METHODS A structured electronic search combining common terms for unipolar depression and utility was conducted in MEDLINE, EMBASE, and PsycINFO. Utility values identified were summarized, and the study designs were appraised in terms of the patient population and valuation method used to generate utilities. Random-effect meta-analyses were applied to pool mean utilities identified for 3 depressive health states (mild, moderate, and severe) elicited from direct and indirect valuation methods separately. RESULTS Thirty-five studies were identified that reported utilities for various levels of depression severity. The most commonly used direct valuation method for eliciting utilities was standard gamble (SG) (n = 5), and the most commonly used indirect valuation method was EQ-5D (n = 20). The pooled mean (standard deviation) utilities from studies using SG as a direct valuation method were mild = 0.69 (0.14), moderate = 0.52 (0.28), and severe = 0.27 (0.26). The pooled utilities from studies using EQ-5D as an indirect valuation method were mild = 0.56 (0.16), moderate = 0.45 (0.18), and severe = 0.25 (0.15). CONCLUSIONS This systematic review is a useful resource for decision analysts who need health-related utility values to populate model-based cost-utility analyses of health interventions for the management of unipolar depression. Further research is necessary to understand whether direct or indirect valuation methods are the most robust sources for utilities in depression.
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Affiliation(s)
- Syed Mohiuddin
- Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK (SM, KP)
| | - Katherine Payne
- Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK (SM, KP)
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Sonntag M, König HH, Konnopka A. The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review. PHARMACOECONOMICS 2013; 31:1131-54. [PMID: 24293216 DOI: 10.1007/s40273-013-0107-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach. METHODS We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D). RESULTS We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies. LIMITATIONS We only searched four databases and did not evaluate the quality of the included studies. CONCLUSIONS Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.
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Affiliation(s)
- Michael Sonntag
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany,
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Lenox-Smith A, Macdonald MTB, Reed C, Tylee A, Peveler R, Quail D, Wildgust HJ. Quality of Life in Depressed Patients in UK Primary Care: The FINDER Study. Neurol Ther 2013; 2:25-42. [PMID: 26000214 PMCID: PMC4389033 DOI: 10.1007/s40120-013-0006-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To investigate the impact of depression and its treatment on health-related quality of life (HRQoL) in a naturalistic, primary care setting in the UK. METHODS The Factors Influencing Depression Endpoints Research (FINDER) study was a European, 6-month, prospective, observational study designed to estimate HRQoL in patients with a clinical diagnosis of depression. This paper examines primary care patients recruited in the UK. HRQoL was measured at baseline and at 3 and 6 months after starting antidepressant therapy using the Short Form 36 Health Status Survey and the European Quality of Life-5 Dimensions (EQ-5D). Regression analysis was used to identify baseline and treatment variables independently and significantly associated with HRQoL. Further analyses included the effect of caseness for depression on HRQoL, the effect of moderate/severe pain at baseline on HRQoL, changes in overall pain, pain interference scores, and the use of different antidepressants by pain cohort. RESULTS A total of 608 patients was recruited from 58 centres and mean HRQoL was significantly below reported population norms at baseline. Most improvement in HRQoL was seen at 3 months for EQ-5D, with small additional improvement at 6 months. Worse HRQoL outcomes at 6 months were associated with higher somatic symptoms score, duration of depression at baseline, and switching within antidepressant classes. Patients meeting the criteria for caseness for depression, or with significant pain at baseline showed less improvement in HRQoL scores at 6 months. CONCLUSION Patients presenting with depression in primary care show reduced HRQoL compared to population norms. HRQoL improves during antidepressant treatment particularly within the first 3 months. Nonpainful somatic symptoms, socioeconomic factors, depression variables and switching within antidepressant class predict poor HRQoL outcome. Pain is a common symptom in depressed patients and remains after 6 months' treatment. Pain and somatic symptoms should be assessed in all patients with depression in primary care.
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Affiliation(s)
- Alan Lenox-Smith
- Eli Lilly & Company Ltd., Lilly House, Priestley Road, Basingstoke, Hampshire RG24 9NL UK
| | - Mark T. B. Macdonald
- Eli Lilly & Company Ltd., Lilly House, Priestley Road, Basingstoke, Hampshire RG24 9NL UK
| | - Catherine Reed
- Eli Lilly & Company Ltd., Erl Wood Manor, Windlesham, Surrey GU20 6PH UK
| | - Andre Tylee
- Health Services and Population Research Department, Section of Primary Care Mental Health, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London, SE5 8AF UK
| | - Robert Peveler
- Clinical Neurosciences Division, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD UK
| | - Deborah Quail
- Eli Lilly & Company Ltd., Erl Wood Manor, Windlesham, Surrey GU20 6PH UK
| | - Hiram J. Wildgust
- Hiram Consulting Ltd., 11 Cricketers Close, Ackworth, Pontefract, West Yorkshire, WF7 7PW UK
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Transcranial magnetic stimulation (TMS) for major depression: a multisite, naturalistic, observational study of quality of life outcome measures in clinical practice. CNS Spectr 2013; 18:322-32. [PMID: 23895940 DOI: 10.1017/s1092852913000357] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Transcranial magnetic stimulation (TMS) is an effective and safe therapy for major depressive disorder (MDD). This study assessed quality of life (QOL) and functional status outcomes for depressed patients after an acute course of TMS. METHODS Forty-two, U.S.-based, clinical TMS practice sites treated 307 outpatients with a primary diagnosis of MDD and persistent symptoms despite prior adequate antidepressant pharmacotherapy. Treatment parameters were based on individual clinical considerations and followed the labeled procedures for use of the approved TMS device. Patient self-reported QOL outcomes included change in the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the EuroQol 5-Dimensions (EQ-5D) ratings from baseline to end of the acute treatment phase. RESULTS Statistically significant improvement in functional status on a broad range of mental health and physical health domains was observed on the SF-36 following acute TMS treatment. Similarly, statistically significant improvement in patient-reported QOL was observed on all domains of the EQ-5D and on the General Health Perception and Health Index scores. Improvement on these measures was observed across the entire range of baseline depression symptom severity. CONCLUSION These data confirm that TMS is effective in the acute treatment of MDD in routine clinical practice settings. This symptom benefit is accompanied by statistically and clinically meaningful improvements in patient-reported QOL and functional status outcomes.
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Moore RA, Derry S, Wiffen PJ. Challenges in design and interpretation of chronic pain trials. Br J Anaesth 2013; 111:38-45. [PMID: 23794643 DOI: 10.1093/bja/aet126] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The process of systematic review has shone a light on the methodology of randomized controlled trials. Notably, a range of potential biases hinders the interpretation of chronic pain trials. These include a consistent bias favouring active over placebo in trials that are small and of short duration. The use of the 'last observation carried forward' imputation method is known to inflate results, often generating statistically significance when adverse event withdrawals are high; in clinical practice terms, this is the wrong answer. Patients want outcomes of low pain scores, large reductions in pain and relief from associated symptoms, with improvements in ability to function and in quality of life. Some patients achieve this, but many do not. The distribution of benefit is skewed and the use of average pain scores, or change in pain, can be misleading compared with responder analysis in which withdrawal is regarded as non-response. Historically, chronic pain trials have had a simple classic or a crossover design. They have been small and short, and used inappropriate imputation and outcomes unconnected to the experiences of most patients. While these designs are useful for answering some questions, they may be insensitive for many interventions. Newer designs, like enriched enrolment randomized withdrawal (EERW) trials or clinical effectiveness trials, are potentially more interesting and informative.
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Affiliation(s)
- R A Moore
- Pain Research and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, The Churchill, Oxford OX3 7LE, UK.
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Magni LR, Purgato M, Gastaldon C, Papola D, Furukawa TA, Cipriani A, Barbui C. Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database Syst Rev 2013:CD004185. [PMID: 24353997 DOI: 10.1002/14651858.cd004185.pub3] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Depression is common in primary care and is associated with marked personal, social and economic morbidity, thus creating significant demands on service providers. The antidepressant fluoxetine has been studied in many randomised controlled trials (RCTs) in comparison with other conventional and unconventional antidepressants. However, these studies have produced conflicting findings.Other systematic reviews have considered selective serotonin reuptake inhibitor (SSRIs) as a group which limits the applicability of the indings for fluoxetine alone. Therefore, this review intends to provide specific and clinically useful information regarding the effects of fluoxetine for depression compared with tricyclics (TCAs), SSRIs, serotonin-noradrenaline reuptake inhibitors (SNRIs), monoamineoxidase inhibitors (MAOIs) and newer agents, and other conventional and unconventional agents. OBJECTIVES To assess the effects of fluoxetine in comparison with all other antidepressive agents for depression in adult individuals with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group Controlled Trials Register (CCDANCTR)to 11May 2012. This register includes relevant RCTs from the Cochrane Central Register of Controlled Trials (CENTRAL) (all years),MEDLINE (1950 to date), EMBASE (1974 to date) and PsycINFO (1967 to date). No language restriction was applied. Reference lists of relevant papers and previous systematic reviews were handsearched. The pharmaceutical company marketing fluoxetine and experts in this field were contacted for supplemental data. SELECTION CRITERIA All RCTs comparing fluoxetine with any other AD (including non-conventional agents such as hypericum) for patients with unipolar major depressive disorder (regardless of the diagnostic criteria used) were included. For trials that had a cross-over design only results from the first randomisation period were considered. DATA COLLECTION AND ANALYSIS Data were independently extracted by two review authors using a standard form. Responders to treatment were calculated on an intention-to-treat basis: dropouts were always included in this analysis. When data on dropouts were carried forward and included in the efficacy evaluation, they were analysed according to the primary studies; when dropouts were excluded from any assessment in the primary studies, they were considered as treatment failures. Scores from continuous outcomes were analysed by including patients with a final assessment or with the last observation carried forward. Tolerability data were analysed by calculating the proportion of patients who failed to complete the study due to any causes and due to side effects or inefficacy. For dichotomous data, odds ratios (ORs) were calculated with 95% confidence intervals (CI) using the random-effects model. Continuous data were analysed using standardised mean differences (SMD) with 95% CI. MAIN RESULTS A total of 171 studies were included in the analysis (24,868 participants). The included studies were undertaken between 1984 and 2012. Studies had homogenous characteristics in terms of design, intervention and outcome measures. The assessment of quality with the risk of bias tool revealed that the great majority of them failed to report methodological details, like the method of random sequence generation, the allocation concealment and blinding. Moreover, most of the included studies were sponsored by drug companies, so the potential for overestimation of treatment effect due to sponsorship bias should be considered in interpreting the results. Fluoxetine was as effective as the TCAs when considered as a group both on a dichotomous outcome (reduction of at least 50% on the Hamilton Depression Scale) (OR 0.97, 95% CI 0.77 to 1.22, 24 RCTs, 2124 participants) and a continuous outcome (mean scores at the end of the trial or change score on depression measures) (SMD 0.03, 95% CI -0.07 to 0.14, 50 RCTs, 3393 participants). On a dichotomousoutcome, fluoxetine was less effective than dothiepin or dosulepin (OR 2.13, 95% CI 1.08 to 4.20; number needed to treat (NNT) =6, 95% CI 3 to 50, 2 RCTs, 144 participants), sertraline (OR 1.37, 95% CI 1.08 to 1.74; NNT = 13, 95% CI 7 to 58, 6 RCTs, 1188 participants), mirtazapine (OR 1.46, 95% CI 1.04 to 2.04; NNT = 12, 95% CI 6 to 134, 4 RCTs, 600 participants) and venlafaxine(OR 1.29, 95% CI 1.10 to 1.51; NNT = 11, 95% CI 8 to 16, 12 RCTs, 3387 participants). On a continuous outcome, fluoxetine was more effective than ABT-200 (SMD -1.85, 95% CI -2.25 to -1.45, 1 RCT, 141 participants) and milnacipran (SMD -0.36, 95% CI-0.63 to -0.08, 2 RCTs, 213 participants); conversely, it was less effective than venlafaxine (SMD 0.10, 95% CI 0 to 0.19, 13 RCTs,3097 participants). Fluoxetine was better tolerated than TCAs considered as a group (total dropout OR 0.79, 95% CI 0.65 to 0.96;NNT = 20, 95% CI 13 to 48, 49 RCTs, 4194 participants) and was better tolerated in comparison with individual ADs, in particular amitriptyline (total dropout OR 0.62, 95% CI 0.46 to 0.85; NNT = 13, 95% CI 8 to 39, 18 RCTs, 1089 participants), and among the newer ADs ABT-200 (total dropout OR 0.18, 95% CI 0.08 to 0.39; NNT = 3, 95% CI 2 to 5, 1 RCT, 144 participants), pramipexole(total dropout OR 0.12, 95% CI 0.03 to 0.42, NNT = 3, 95% CI 2 to 5, 1 RCT, 105 participants), and reboxetine (total dropout OR0.60, 95% CI 0.44 to 0.82, NNT = 9, 95% CI 6 to 24, 4 RCTs, 764 participants). AUTHORS' CONCLUSIONS The present study detected differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain.Moreover, the assessment of quality with the risk of bias tool showed that the great majority of included studies failed to report details on methodological procedures. Of consequence, no definitive implications can be drawn from the studies' results. The better efficacy profile of sertraline and venlafaxine (and possibly other ADs) over fluoxetine may be clinically meaningful,as already suggested by other systematic reviews. In addition to efficacy data, treatment decisions should also be based on considerations of drug toxicity, patient acceptability and cost.
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Mencacci C, Di Sciascio G, Katz P, Ripellino C. Cost-effectiveness evaluation of escitalopram in major depressive disorder in Italy. CLINICOECONOMICS AND OUTCOMES RESEARCH 2013; 5:87-99. [PMID: 23413176 PMCID: PMC3570079 DOI: 10.2147/ceor.s39492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Depression has a lifetime prevalence of 10%–25% among women and 5%–12% among men. Selective serotonin reuptake inhibitors (SSRIs) are the most used and the most cost-effective treatment for long-term major depressive disorder. Since the introduction of generic SSRIs, the costs of branded drugs have been questioned. The objective of this study was to assess the cost-effectiveness (€ per quality-adjusted life year [QALY]) of escitalopram (which is still covered by a patent) compared with paroxetine, sertraline, and citalopram, the patents for which have expired. Methods A decision analytic model was adapted from the Swedish Dental and Pharmaceutical benefits agency model to reflect current clinical practice in the treatment of depression in Italy in collaboration with an expert panel of Italian psychiatrists and health economists. The population comprised patients with a first diagnosis of major depressive disorder and receiving for the first time one of the following SSRIs: escitalopram, sertraline, paroxetine, and citalopram. The time frame used was 12 months. Efficacy and utility data for the original model were validated by our expert panel. Local data were considered for resource utilization and for treatment costs based on the Lombardy region health service perspective. Several scenario simulations, oneway sensitivity analyses, and Monte Carlo simulations were performed to test the robustness of the model. Results The base case scenario showed that escitalopram had an incremental cost-effectiveness ratio (ICER) of €4395 and €1080 per QALY compared with sertraline and paroxetine, respectively. Escitalopram was dominant over citalopram, which was confirmed by most one-way sensitivity analyses. The escitalopram strategy gained 0.011 QALYs more than citalopram, 0.008 more than paroxetine, and around 0.007 more than sertraline. Monte Carlo simulations indicated that ICER values for escitalopram were centered around €1100 and €4400 per QALY compared with paroxetine and sertraline, respectively. Although there is no official cost-effectiveness threshold in Italy, the value of €25,000 per QALY could be acceptable. All ICER values retrieved in all analyses were lower than this threshold. Conclusion The findings from this cost-effectiveness analysis indicate that escitalopram could be accepted as a cost-effective strategy for the Lombardy region health service compared with the other SSRIs studied. The present assessment is based on ICER values resulting from this analysis, which are lower than the thresholds proposed by health care authorities in other European Union countries. These benefits are driven by the effectiveness of escitalopram, which result in an improved health-related quality of life, a higher probability of sustained remission, and better utilization of health care resources. The study results are robust and in line with other pharmacoeconomic analyses comparing escitalopram with other SSRIs.
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Dantchev N, Tcherny-Lessenot S, Picard H, Baraille L, Quail D. [Results of the French cohort of the European observational study FINDER: quality of life of patients treated with antidepressants]. Encephale 2012; 39:101-8. [PMID: 23095580 DOI: 10.1016/j.encep.2012.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 03/07/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To describe health-related quality of life (HRQoL), pain, clinical outcomes and treatment patterns in French patients with depression treated by general practitioners and psychiatrists. METHODS Factors Influencing Depression Endpoints Research (FINDER) is a European longitudinal observational, naturalistic, multicentre study to determine the HRQoL (SF-36 and EQ-5D) and to assess outcomes of depression and anxiety (Hospital Anxiety and Depression Scale [HADS]), and pain (VAS) in a population of depressed patients initiating antidepressant treatment. Clinical diagnosis of depression was based on physician's clinical judgment. Physicians decided at their own discretion and clinical practice to initiate pharmacological treatment for depression. Adult patients with a first or new episode of depression were enrolled between May 2004 and September 2005, and followed up for 6 months. Across Europe, 437 physicians observed 3468 patients. RESULTS In France, 606 patients (approximately 17% of the whole sample) were enrolled by 57 psychiatrists and 46 general practitioners. These patients were (mean ± SD) 45.6 ± 13.0 years old, 69% female and 39% having had a previous depressive episode in the last 2 years. According to the patient-rated HADS score greater or equal to 11, most patients (75%) were classified as cases of depression as well as cases of anxiety (84%); 51% of patients rated their overall pain severity (based on VAS cut-off of 30 mm) as moderate/severe, with 65% of these patients reporting no medical explanation for their pain. The majority (81%) of the patients were prescribed selective serotonin reuptake inhibitors (SSRI). During the 6-month follow-up, the majority of the patients (73%) remained on the same antidepressant at the same dose during the course of treatment. Between baseline and 6-month endpoint, French patients improved their mean scores (SD) on the SF-36 physical score by+3.5 (9.0) (P<0.001) and mental score by+20.6 (14.2) (P<0.001); on the EQ-5D Health State Index by+0.37 (0.32) (P<0.001) and the EQ-5D VAS by+32.3 (25.0) (P<0.001); on the HADS depression score by-8.1 (6.0) (P<0.001) and HADS anxiety score by-6.9 (5.0) (P<0.001). Patients with moderate/severe pain at baseline improved their overall pain on a mean VAS score by-34.1 (28.7) (P<0.001). CONCLUSIONS More than half of the French patients enrolled in the study experienced pain associated with depression. During follow-up, patients improved all of their outcome measurements (physical and mental SF-36 scores, depression and anxiety HADS scores, pain VAS, EQ-5D Health State Index and VAS) and most patients remained on the same antidepressant at the same dose.
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Affiliation(s)
- N Dantchev
- Unité de psychiatrie, Hôtel-Dieu, 1, place du Parvis-Notre-Dame, 75181 Paris cedex 4, France.
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Pan YJ, Knapp M, McCrone P. Cost-effectiveness comparisons between antidepressant treatments in depression: evidence from database analyses and prospective studies. J Affect Disord 2012; 139:113-25. [PMID: 21851987 DOI: 10.1016/j.jad.2011.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Knowledge regarding the relative cost-effectiveness of different antidepressants is crucial for the planning of depression treatment. However, there have been only a small number of reviews of such evidence and synthesizing economic evidence across studies is methodologically challenging. In particular, there have been few reviews of the methods employed in database analyses (studies that use data from real-world practice). METHODS Published economic evaluations based on database analyses were systematically reviewed to compare antidepressant treatments in depression. Prospective studies of cost-effectiveness were also reviewed to highlight unanswered questions through comparisons between these two different study designs. RESULTS Forty papers met the criteria and were included. A relatively large number of industry-sponsored evaluations of escitalopram were identified and these found escitalopram to be potentially cost-effective in depression treatment. Evidence of cost-effectiveness differences between other individual SSRIs was not unequivocally established. Inconsistent findings further emerged concerning the cost-effectiveness of SSRIs versus TCAs between retrospective database analyses and prospective studies. LIMITATIONS Different outcome measures and cost perspectives make it difficult to make comparisons across studies. CONCLUSIONS Evidence regarding the cost-effectiveness of different antidepressants in depression continues to accumulate. Beyond the efficacy or tolerability data found for newer antidepressants in controlled trials, further research from real-world settings is needed to examine the relative cost-effectiveness of different antidepressant agents.
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Affiliation(s)
- Yi-Ju Pan
- Centre for the Economics of Mental Health, Health Service and Population Research Department, Institute of Psychiatry at King's College London, United Kingdom.
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Krol M, Papenburg J, Koopmanschap M, Brouwer W. Do productivity costs matter?: the impact of including productivity costs on the incremental costs of interventions targeted at depressive disorders. PHARMACOECONOMICS 2011; 29:601-19. [PMID: 21545189 DOI: 10.2165/11539970-000000000-00000] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND When guidelines for health economic evaluations prescribe that a societal perspective should be adopted, productivity costs should be included. However, previous research suggests that, in practice, productivity costs are often neglected. This may considerably bias the results of cost-effectiveness studies, particularly those regarding treatments targeted at diseases with a high incidence rate in the working population, such as depressive disorders. OBJECTIVES This study aimed to, first, investigate whether economic evaluations of treatments for depressive disorders include productivity costs and, if so, how. Second, to investigate how the inclusion or exclusion of productivity costs affects incremental costs. METHODS A systematic literature review was performed. Included articles were reviewed to determine (i) whether productivity costs had been included and (ii) whether the studies adhered to national health economic guidelines about the inclusion or exclusion of these costs. For those studies that did include productivity costs, we calculated what proportion of total costs were productivity costs. Subsequently, the incremental costs, excluding productivity costs, were calculated and compared with the incremental costs presented in the original article, to analyse the impact of productivity costs on final results. Regression analyses were used to investigate the relationship between the level of productivity costs and the type of depressive disorder, the type of treatment and study characteristics such as time horizon used and productivity cost valuation method. RESULTS A total of 81 unique economic evaluations of treatments for adults with depressive disorders were identified, 24 of which included productivity costs in the numerator and one in the denominator. Approximately 69% of the economic evaluations ignored productivity costs. Two-thirds of the studies complied with national guidelines regarding the inclusion of productivity costs. For the studies that included productivity costs, these costs reflected an average of 60% of total costs per treatment arm. The inclusion or exclusion of productivity costs substantially affected incremental costs in a number of studies. Regression analyses showed that the level of productivity costs was significantly associated with study characteristics such as average age, the methods of data collection regarding work time lost, the values attached to lost work time, the type of depressive disorder, the type of treatment provided and the level of direct costs. CONCLUSIONS Studies that do not include productivity costs may, in many cases, poorly reflect full societal costs (or savings) of an intervention. Furthermore, when comparing total costs reported in studies that include productivity costs, it should be noted that study characteristics such as the methods used to assess productivity costs may affect their level.
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Affiliation(s)
- Marieke Krol
- Department of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands.
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Dowrick C, Flach C, Leese M, Chatwin J, Morriss R, Peveler R, Gabbay M, Byng R, Moore M, Tylee A, Kendrick T. Estimating probability of sustained recovery from mild to moderate depression in primary care: evidence from the THREAD study. Psychol Med 2011; 41:141-150. [PMID: 20346195 DOI: 10.1017/s0033291710000437] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND It is important for doctors and patients to know what factors help recovery from depression. Our objectives were to predict the probability of sustained recovery for patients presenting with mild to moderate depression in primary care and to devise a means of estimating this probability on an individual basis. METHOD Participants in a randomized controlled trial were identified through general practitioners (GPs) around three academic centres in England. Participants were aged >18 years, with Hamilton Depression Rating Scale (HAMD) scores 12-19 inclusive, and at least one physical symptom on the Bradford Somatic Inventory (BSI). Baseline assessments included demographics, treatment preference, life events and difficulties and health and social care use. The outcome was sustained recovery, defined as HAMD score <8 at both 12 and 26 week follow-up. We produced a predictive model of outcome using logistic regression clustered by GP and created a probability tree to demonstrate estimated probability of recovery at the individual level. RESULTS Of 220 participants, 74% provided HAMD scores at 12 and 26 weeks. A total of 39 (24%) achieved sustained recovery, associated with being female, married/cohabiting, having a low BSI score and receiving preferred treatment. A linear predictor gives individual probabilities for sustained recovery given specific characteristics and probability trees illustrate the range of probabilities and their uncertainties for some important combinations of factors. CONCLUSIONS Sustained recovery from mild to moderate depression in primary care appears more likely for women, people who are married or cohabiting, have few somatic symptoms and receive their preferred treatment.
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Affiliation(s)
- C Dowrick
- Division of Primary Care, University of Liverpool, Liverpool, UK.
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Ridyard CH, Hughes DA. Methods for the collection of resource use data within clinical trials: a systematic review of studies funded by the UK Health Technology Assessment program. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:867-72. [PMID: 20946187 DOI: 10.1111/j.1524-4733.2010.00788.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND The UK Health Technology Assessment (HTA) program funds trials that address issues of clinical and cost-effectiveness to meet the needs of the National Health Service (NHS). The objective of this review was to systematically assess the methods of resource use data collection and costing; and to produce a best practice guide for data capture within economic analyses alongside clinical trials. METHODS All 100 HTA-funded primary research papers published to June 2009 were reviewed for the health economic methods employed. Data were extracted and summarized by: health technology assessed, costing perspective adopted, evidence of planning and piloting, data collection method, frequency of data collection, and sources of unit cost data. RESULTS Ninety-five studies were identified as having conducted an economic analysis, of which 85 recorded patient-level resource use. The review identified important differences in how data are collected. These included: a priori evidence of analysts having identified important cost drivers; the piloting and validation of patient-completed resource use questionnaires; choice of costing perspective; and frequency of data collection. Areas of commonality included: the extensive use of routine medical records and reliance on patient recall; and the use of standard sources of unit costs. CONCLUSION Economic data collection is variable, even among a homogeneous selection of trials designed to meet the needs of a common organization (NHS). Areas for improvement have been identified, and based on our findings and related reviews and guidelines, a checklist is proposed for good practice relating to economic data collection within clinical trials.
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Affiliation(s)
- Colin H Ridyard
- Centre for Economics & Policy in Health, Institute of Medical and Social Care Research, Bangor University, Bangor, Gwynedd, UK
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Avram S, Buiu C, Duda-Seiman DM, Duda-Seiman C, Mihailescu D. 3D-QSAR design of new escitalopram derivatives for the treatment of major depressive disorders. Sci Pharm 2010; 78:233-48. [PMID: 21179345 PMCID: PMC3002802 DOI: 10.3797/scipharm.0912-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 05/04/2010] [Indexed: 11/22/2022] Open
Abstract
Antidepressants are psychiatric agents used for the treatment of different types of depression being at present amongst the most commonly prescribed drug, while their effectiveness and adverse effects are the subject of many studies and competing claims. Having studied five QSAR models predicting the biological activities of 18 antidepressants, already approved for clinical treatment, in interaction with the serotonin transporter (SERT), we attempted to establish the membrane ionsâ contributions (sodium, potassium, chlorine and calcium) supplied by donor/acceptor hydrogen bond character and electrostatic field to the antidepressant activity. Significant cross-validated correlation q(2) (0.5â0.6) and the fitted correlation r(2) (0.7â0.82) coefficients were obtained indicating that the models can predict the antidepressant activity of compounds. Moreover, considering the contribution of membrane ions (sodium, potassium and calcium) and hydrogen bond donor character, we have proposed a library of 24 new escitalopram structures, some of them probably with significantly improved antidepressant activity in comparison with the parent compound.
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Affiliation(s)
- Speranta Avram
- Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, 91-95, Splaiul Independentei, RO-76201, Bucharest, Romania.
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Effects of pharmacotherapy and psychotherapy in depressed primary-care patients: a randomized, controlled trial including a patients' choice arm. Int J Neuropsychopharmacol 2010; 13:31-44. [PMID: 19341510 DOI: 10.1017/s1461145709000224] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Mild depressive syndromes are highly prevalent among primary-care patients. Evidence-based treatment recommendations need to be derived directly from this diagnostically heterogeneous group. The primary aim was to assess the efficacy of sertraline and cognitive-behavioural group therapy for treatment of depressed primary-care patients, the secondary aim was to evaluate if receiving treatment according to free choice is associated with a better outcome than randomization to a particular treatment. We conducted a randomized, placebo-controlled, single-centre, 10-wk trial with five arms: sertraline (flexible dosages up to 200 mg/d) (n = 83); placebo (n = 83); manual-guided cognitive-behavioural group therapy (one individual session and nine group sessions per 90 min) (n = 61); guided self-help group (control condition, n = 59); and treatment with sertraline or cognitive-behavioural group therapy according to patients' choice (n = 82). From 1099 consecutively screened adult patients, 368 formed the intent-to-treat population with milder forms of depression. Primary outcome was a global efficacy measure combining z-converted Hamilton Depression Rating Scale and clinician-rated Inventory for Depressive Symptomatology scores. Sertraline was superior to placebo (p = 0.03). Outcome for guided self-help groups was worse compared to cognitive-behavioural group therapy (p = 0.002) and compared to all other treatment arms including pill placebo (secondary analyses). Outcome in the patients' choice arm was similar to that in the sertraline and cognitive-behavioural group therapy. Overall, sertraline is efficacious in primary-care patients with milder forms of depression. The superiority of cognitive-behavioural group therapy over guided self-help groups might partly be explained by 'nocebo' effects of the latter.
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Wu EQ, Ben-Hamadi R, Yu AP, Tang J, Haim Erder M, Bose A. Healthcare utilization and costs incurred by patients with major depression after being switched from escitalopram to another SSRI for non-medical reasons. J Med Econ 2010; 13:314-23. [PMID: 20504111 DOI: 10.3111/13696998.2010.488985] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare healthcare utilization and costs for major depressive disorder (MDD) patients treated with escitalopram and who were switched to another SSRI for non-medical reasons versus those who did not switch. RESEARCH DESIGN AND METHODS Patients were identified in the Ingenix Impact Database (2003-2006). The analysis group included patients who remained on escitalopram for ≥ 90 days and switched to another SSRI within 45 days of end of supply days for non-medical reasons; the control group included matched individuals who did not switch within 45 days. Switching for medical reasons was defined as switching within 7 days after having a hospitalization, an emergency room (ER) visit, or a psychotherapy visit. Outcomes (all-cause and MDD-related) were analyzed over 3 months and included use of hospital, ER, outpatient visits and professional services, and healthcare costs. Outcomes were compared between the two groups using descriptive statistics and regression analyses controlling for differences in baseline characteristics. Costs were inflation adjusted to 2006 US dollars. RESULTS The study included 2,805 matched pairs. Compared to controls, switchers had higher rates of all-cause and MDD-related hospitalizations (relative risk [RR] = 1.4 and 2.0, respectively) and all-cause and MDD-related ER visits (RR = 1.2 and 1.6, respectively, all p ≤ 0.05). Results from multivariate analyses show that switchers had higher medical costs (+$138), drug costs (+$149) and total healthcare costs (+$322) compared to patients in the control group (all p < 0.0001). LIMITATIONS This study's limitations include its short observational period and definition of switching for non-medical reasons. CONCLUSION Patients who were switched to another SSRI for non-medical reasons after being stabilized on escitalopram used more resources and had higher healthcare costs within 3 months of switching than patients who did not switch.
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Affiliation(s)
- Eric Q Wu
- Analysis Group, Inc., 111 Huntington Avenue, Boston, MA 02199, USA.
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Yu AP, Xie J, Bensimon A, Parikh K, Wu EQ, Ben-Hamadi R, Blum S, Haim Erder M. Economic consequence of switching to citalopram after its generic entry for adult patients with major depressive disorder (MDD) treated with escitalopram: a 6-month retrospective study. J Med Econ 2010; 13:599-609. [PMID: 20879834 DOI: 10.3111/13696998.2010.521736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To estimate, from a third-party payer's perspective, the effects of switching from escitalopram to citalopram, after the generic entry of citalopram, on hospitalization and healthcare costs among adult MDD patients who were on escitalopram therapy. METHODS Adult MDD patients treated with escitalopram were identified from Ingenix Impact claims database. MDD- and mental health (MH)-related hospitalization rates and healthcare costs were compared between 'switchers' (patients who switched to citalopram after its generic entry) and 'non-switchers'. MDD- and MH-related outcomes were defined as having a primary or a secondary diagnosis of ICD-9-CM = 296.2x, 296.3x and ICD-9-CM = 290-319, respectively. A propensity score matching method that estimated the likelihood of switching using baseline characteristics was used. Outcomes were examined for both 3-month and 6-month post-index periods. RESULTS The sample included 3,427 matched pairs with balanced baseline characteristics. Switchers were more likely to incur an MDD-related (odds ratio [OR] = 1.52) and MH-related hospitalization (OR = 1.34) during the 6-month post-index period (both p < 0.05). Compared to switchers, non-switchers had significantly lower MDD- and MH-related hospitalization costs ($248.3 and $219.8 lower, respectively) and medical costs ($277.4 and $246.4 lower, respectively) (all p < 0.05). Although non-switchers had significantly higher MDD- and MH-related prescription drug costs, overall they had significantly lower total MDD- and MH-related healthcare costs ($109.9 and $93.6 lower, respectively; both p < 0.001). The 3-month results were consistent with these 6-month findings. LIMITATIONS The study limitations included limited generalizability of study findings, inability to differentiate switching from escitalopram to citalopram due to medical reasons versus non-medical reasons, and exclusion of indirect costs from cost calculations. CONCLUSIONS Compared to patients maintaining on escitalopram, switchers from escitalopram to citalopram experienced higher risk of MDD- and MH-related hospitalization and incurred higher total MDD- and MH-related healthcare costs. The economic consequences of therapeutic substitution should take into account total healthcare costs, not just drug acquisition costs.
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Affiliation(s)
- Andrew P Yu
- Analysis Group, Inc., Boston, MA 02199, USA.
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Putting the 'Q' in depression QALYs: a comparison of utility measurement using EQ-5D and SF-6D health related quality of life measures. Soc Psychiatry Psychiatr Epidemiol 2009; 44:569-78. [PMID: 19011721 DOI: 10.1007/s00127-008-0463-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 10/20/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Generic health preference measures that capture quality of life improvements in depression are important for economic analysis of new technologies. AIM To compare two widely used preference measures, the EQ-5D and SF-6D, in terms of their dimensions and health utility values. METHOD EQ-5D and SF-6D data collected from 114 patients with depression, who participated in a cluster, randomised controlled trial to evaluate a collaborative care intervention in UK, primary care practices. Utilities were examined across the whole sample and by level of depression severity using the PHQ-9. RESULTS Depression was associated with disutility at baseline. At 3 month follow-up mean utility increased 0.147 for EQ-5D and 0.082 for SF-6D. Health gains were observed in patients in remission from depression and those with the mildest level of depression severity. CONCLUSIONS Both generic preference measures were sensitive to health gains in depression within a relatively short follow-up period; larger health gain was observed for the EQ-5D.
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Reed C, Monz BU, Perahia DGS, Gandhi P, Bauer M, Dantchev N, Demyttenaere K, Garcia-Cebrian A, Grassi L, Quail D, Tylee A, Montejo AL. Quality of life outcomes among patients with depression after 6 months of starting treatment: results from FINDER. J Affect Disord 2009; 113:296-302. [PMID: 18603303 DOI: 10.1016/j.jad.2008.05.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 05/27/2008] [Accepted: 05/27/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Health-related quality of life (HRQoL) data in depression are limited. We studied the impact of antidepressant (AD) treatment on HRQoL outcomes in depressed patients and investigated factors associated with these outcomes in routine practice settings. METHODS The Factors Influencing Depression Endpoints Research (FINDER) study was a 6-month, European, prospective, observational study, designed to estimate HRQoL in 3468 adult patients with a clinically diagnosed episode of depression at baseline and at 3 and 6-months after commencing AD treatment. HRQoL was assessed by the Medical Outcome Short-Form (36) Health Survey (SF-36) and European Quality of Life-5 Dimensions (EQ-5D). Regression analysis identified baseline and treatment variables independently and significantly associated with HRQoL outcomes. RESULTS Most HRQoL improvement occurred within 3 months of starting treatment. Better HRQoL outcomes were strongly associated with fewer somatic symptoms at baseline, AD treatment taken and not switching within AD groups. Education and occupational status were also important. Depression variables (number of previous depressions and current episode duration) were consistently associated with worse HRQoL outcomes. Self-rated depression severity was associated with poorer outcomes on the SF-36 mental component only. LIMITATIONS As this was an observational study, the important finding that between and within AD group switching impacted HRQoL will need to be investigated in more controlled settings. CONCLUSIONS Receiving an AD treatment was associated with large improvements in HRQoL, but switching within AD groups was consistently associated with poorer outcomes. Somatic symptoms, including painful symptoms, are often present in depressed patients and appear to negatively impact HRQoL outcomes.
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Affiliation(s)
- Catherine Reed
- Eli Lilly & Company Ltd., Erl Wood Manor, Windlesham, Surrey, UK.
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Serrano-Blanco A, Suárez D, Pinto-Meza A, Peñarrubia MT, Haro JM. Fluoxetine and imipramine: are there differences in cost-utility for depression in primary care? J Eval Clin Pract 2009; 15:195-203. [PMID: 19239602 DOI: 10.1111/j.1365-2753.2008.00982.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE Depressive disorders generate severe personal burden and high economic costs. Cost-utility analyses of the different therapeutical options are crucial to policy-makers and clinicians. Previous cost-utility studies, comparing selective serotonin reuptake inhibitors and tricyclic antidepressants, have used modelling techniques or have not included indirect costs in the economic analyses. OBJECTIVE To determine the cost-utility of fluoxetine compared with imipramine for treating depressive disorders in primary care. METHODS A 6-month randomized prospective naturalistic study comparing fluoxetine with imipramine was conducted in three primary care centres in Spain. One hundred and three patients requiring antidepressant treatment for a DSM-IV depressive disorder were included in the study. Patients were randomized either to fluoxetine (53 patients) or to imipramine (50 patients) treatment. Patients were treated with antidepressants according to their general practitioner's usual clinical practice. Outcome measures were the quality of life tariff of the European Quality of Life Questionnaire: EuroQoL-5D (five domains), direct costs, indirect costs and total costs. Subjects were evaluated at the beginning of treatment and after 1, 3 and 6 months. Incremental cost-utility ratios (ICUR) were obtained. 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, imipramine dominated fluoxetine with 81.5% of the bootstrap replications in the dominance quadrant. CONCLUSION Imipramine seems to be a better cost-utility antidepressant option for treating depressive disorders in primary care.
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Affiliation(s)
- Antoni Serrano-Blanco
- Sant Joan de Déu-Serveis de Salut Mental, Fundació Sant Joan de Déu, Sant Boi de Ll, Barcelona, Spain.
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Assessment of the prescription of antidepressant drugs in elderly nursing home patients: a clinical and laboratory follow-up investigation. J Clin Psychopharmacol 2008; 28:424-31. [PMID: 18626270 DOI: 10.1097/jcp.0b013e31817d79eb] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The aim of the study was to investigate the use of antidepressant drugs among elderly people in nursing homes. Elderly residents who where found to have been prescribed at least one antidepressant drug according to the specific medication dispensing system were identified in 8 nursing homes in the county of Ostergötland, Sweden. Data were collected from the medical record forms at the nursing home. Blood samples were drawn for the assessment of drug concentration, blood chemistry parameters and cytochrome P450 expression. At least one antidepressant drug was prescribed to 38% of elderly people in the nursing home studied. A total of 71 patients were evaluated, 80% women and 20% men. The median age was 84 years (range, 71-100 years). Indications for antidepressant drug treatment were found on 96% of medical record forms (depression, 60%); however, information relating to when treatment was initiated could not be found on 34% of medical record forms and a clear time schedule for how long this drug treatment was planned to continue could not be found either. A possible adverse effect of antidepressant drug treatment was retrieved in at least 77% of patients. Polypharmacotherapy was common; median number of drugs per patient was 11. Concentrations of drugs were higher than expected in 73%. Most patients were medicated with citalopram (n = 44). A clear interindividual variability of concentrations at each dose level was found for citalopram and for the metabolites desmethylcitalopram and didesmethylcitalopram. A significant correlation was found between the estimation of creatinine clearance and concentration-dose ratio of citalopram. Poor metabolizers, who had been prescribed an antidepressant drug that are substrate for the cytochrome P450 isoenzyme examined, have higher concentrations of prescribed antidepressant drug than do non-poor metabolizers in relation to dose. An increase in quality contribution to follow-up at antidepressant medications is needed. A more frequent clinical use of therapeutic drug monitoring and pharmacogenetic tests in addition to therapeutic drug monitoring may be one important tool in this process.
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Zdanowicz N, Jacques D, Reynaert C. Comparisons between psychotropic drugs: must the risk of side effects dictate our practices? Acta Clin Belg 2008; 63:235-41. [PMID: 19048700 DOI: 10.1179/acb.2008.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Recently, SOHO and CATIE's studies in the field of schizophrenic disorders asserted that molecules apparently showing the most side-effects are not only the most effective but also lead to the least changes in treatments. Can we generalise this assertion to other domains of pharmacological treatments, such as in mood and anxiety disorders? And, more generally, do we possess information about comparison between different types of molecules in these different fields. METHODS Review of the literature (medline-psycinfo-psycarticles) addressing these three psychiatric disorders, and comparing efficacy of treatments, or cost-effectiveness studies. RESULTS Although there is a plethora of publications about the efficacy of given molecules vs. placebo, studies comparing molecules are scarce, and studies on cost-effectiveness in natural environments are even more scarce. Independently of the type of disorders under study, the last few years' efforts to completely limit side effects seem to have resulted in a loss of efficacy. Moreover, the previously held hypothesis suggesting that the fewer the side effects, the lesser the need to change treatment has not been confirmed. The duration of a treatment is more dependent upon its efficacy than on other variables. CONCLUSIONS Clinicians cannot determine the absence of noxiousness of a molecule as their primary criterion of choice. In contrast, they should carefully balance side effects and efficacy. In Psychiatry, there is a lack of studies about cost-effectiveness in natural environments.
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Affiliation(s)
- N Zdanowicz
- Medicine Faculty, Université Catholique de Louvain, Psychopathology and Psychosomatic unit, Cliniques de Mont-Godinne , 5530 Yvoir, Belgium.
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Anderson IM, Ferrier IN, Baldwin RC, Cowen PJ, Howard L, Lewis G, Matthews K, McAllister-Williams RH, Peveler RC, Scott J, Tylee A. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines. J Psychopharmacol 2008; 22:343-96. [PMID: 18413657 DOI: 10.1177/0269881107088441] [Citation(s) in RCA: 335] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.
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Affiliation(s)
- I M Anderson
- Senior Lecturer and Honorary Consultant Psychiatrist, Neuroscience and Psychiatry Unit, University of Manchester, UK.
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Roberts SH, Bedson E, Hughes D, Lloyd K, Moat S, Pirmohamed M, Slegg G, Tranter R, Whitaker R, Wilkinson C, Russell I. Folate augmentation of treatment - evaluation for depression (FolATED): protocol of a randomised controlled trial. BMC Psychiatry 2007; 7:65. [PMID: 18005429 PMCID: PMC2238748 DOI: 10.1186/1471-244x-7-65] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Accepted: 11/15/2007] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinical depression is common, debilitating and treatable; one in four people experience it during their lives. The majority of sufferers are treated in primary care and only half respond well to active treatment. Evidence suggests that folate may be a useful adjunct to antidepressant treatment: 1) patients with depression often have a functional folate deficiency; 2) the severity of such deficiency, indicated by elevated homocysteine, correlates with depression severity, 3) low folate is associated with poor antidepressant response, and 4) folate is required for the synthesis of neurotransmitters implicated in the pathogenesis and treatment of depression. METHODS/DESIGN The primary objective of this trial is to estimate the effect of folate augmentation in new or continuing treatment of depressive disorder in primary and secondary care. Secondary objectives are to evaluate the cost-effectiveness of folate augmentation of antidepressant treatment, investigate how the response to antidepressant treatment depends on genetic polymorphisms relevant to folate metabolism and antidepressant response, and explore whether baseline folate status can predict response to antidepressant treatment. Seven hundred and thirty patients will be recruited from North East Wales, North West Wales and Swansea. Patients with moderate to severe depression will be referred to the trial by their GP or Psychiatrist. If patients consent they will be assessed for eligibility and baseline measures will be undertaken. Blood samples will be taken to exclude patients with folate and B12 deficiency. Some of the blood taken will be used to measure homocysteine levels and for genetic analysis (with additional consent). Eligible participants will be randomised to receive 5 mg of folic acid or placebo. Patients with B12 deficiency or folate deficiency will be given appropriate treatment and will be monitored in the 'comprehensive cohort study'. Assessments will be at screening, randomisation and 3 subsequent follow-ups. DISCUSSION If folic acid is shown to improve the efficacy of antidepressants, then it will provide a safe, simple and cheap way of improving the treatment of depression in primary and secondary care. TRIAL REGISTRATION Current controlled trials ISRCTN37558856.
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Affiliation(s)
- Seren Haf Roberts
- North Wales Section of Psychological Medicine, Institute of Medical and Social Care Research (IMSCaR), Bangor University, Academic Unit, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Emma Bedson
- North Wales Section of Psychological Medicine, Institute of Medical and Social Care Research (IMSCaR), Bangor University, Academic Unit, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Dyfrig Hughes
- Centre for Economics and Policy in Health, IMSCaR, Bangor University, Dean Street, Bangor, Gwynedd, LL57 1UT, UK
| | - Keith Lloyd
- Psychological Medicine, Swansea University, Clinical School, Room 213, Grove Building, Swansea, SA2 8PP, UK
| | - Stuart Moat
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Health Park, Cardiff, CF14 4XW, UK
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Ashton Street, Liverpool, L69 3GE, UK
| | - Gary Slegg
- North Wales Section of Psychological Medicine, Institute of Medical and Social Care Research (IMSCaR), Bangor University, Academic Unit, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Richard Tranter
- North West Wales NHS Trust, Ysbyty Gwynedd, Bangor, Gwynedd, LL57 2PW, UK
| | - Rhiannon Whitaker
- North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical and Social Care Research (IMSCaR), Bangor University, Ardudwy, Normal Site, Bangor, Gwynedd, LL57 2AS, UK
| | - Clare Wilkinson
- Department of General Practice, Cardiff University, Gwenfro Building, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Ian Russell
- Institute of Medical and Social Care Research (IMSCaR), Bangor University, Brigantia Building, Bangor, Gwynedd, LL57 2AS, UK
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Abstract
This paper summarises the use of QALYs in evaluating changes in mental health states, highlighting the benefits and challenges of their use in this field. The general principles underlying the QALY measure and the most common methods of measuring QALYs are discussed briefly. Evidence of the usefulness and problems of using this generic measure of health-related quality of life are provided from a sample of recent studies relating to depression, schizophrenia, attention deficit hyperactivity disorder and dementia. In each case, attempts were made to use QALYs to measure changes in health states. While in principle, the QALY is enormously attractive, its suitability for measuring changes in many mental health conditions remains open to doubt as existing tools for generating QALY scores such as the EQ-5D have tended not to perform sufficiently well in reflecting changes in many mental health states. New developmental work is needed to construct better QALY-measuring tools for use in the mental health field. Both the conceptualisation and measurement of QALYs need to be built on a valid, comprehensive model of quality of life specific to a mental health disorder, to ensure that the resultant tool is sensitive enough to pick up changes that would be expected and seen as relevant in the course of the illness.
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Beich A, Gannik D, Saelan H, Thorsen T. Screening and brief intervention targeting risky drinkers in danish general practice—A pragmatic controlled trial. Alcohol Alcohol 2007; 42:593-603. [PMID: 17855332 DOI: 10.1093/alcalc/agm063] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Recommendations for routine alcohol screening and brief counselling intervention in primary health care rest on results from intervention efficacy studies. By conducting a pragmatic controlled trial (PCT), we aimed at evaluating the effectiveness of the WHO recommendations for screening and brief intervention (SBI) in general practice. METHODS A randomized PCT (brief counselling intervention vs no intervention) involving 39 Danish general practitioners (GPs). Systematic screening of 6897 adults led to inclusion of 906 risky drinkers, and research follow-up on 537 of these after 12-14 months. Outcome measures focused on patients' acceptance of screening and intervention and their self-reported alcohol consumption. RESULTS Patient acceptance of screening and intervention -10.3% (N = 794) of the target population (N = 7, 691) explicitly refused screening. All intervention group subjects (N = 442) were exposed to an instant brief counselling session while only 17.9% of them (79/442) attended a follow-up consultation that was offered by their GP. Consumption Changes At one-year follow-up, average weekly consumption had increased by 0.7 drinks in both comparison groups. As secondary findings, we observed an indiscriminate absolute risk reduction (ARR = 0.08 (95% CI: -0.02; 0.18)) in male binge drinking, but adverse intervention effects for women on the secondary outcomes (binge drinking ARR = -0.30 (95% CI: -0.47; -0.09)). CONCLUSIONS The results of brief interventions in everyday general practice performed on the basis of systematic questionnaire screening may fall short of theoretical expectations. When applied to non-selected groups in everyday general practice SBI may have little effect and engender diverse outcome. Women may be more susceptible to defensive reactions than men.
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Affiliation(s)
- Anders Beich
- Research Unit and Department for General Practice, University of Copenhagen, Centre for Health and Community, Oster Farimagsgade 5, DK-1014 Copenhagen K, Denmark.
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Sobocki P, Ekman M, Agren H, Krakau I, Runeson B, Mårtensson B, Jönsson B. Resource use and costs associated with patients treated for depression in primary care. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2007; 8:67-76. [PMID: 17165073 DOI: 10.1007/s10198-006-0008-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Accepted: 08/28/2006] [Indexed: 05/13/2023]
Abstract
We investigated medical resource consumption, productivity loss and costs associated with patients treated with antidepressants for depression in primary care in Sweden. Patients on treatment for depression were followed naturalistically for six-months, and data on patients' characteristics, daily activity and resource-use were collected. The total cost per patient was estimated at euro 5,500 (95%CI euro 5,000-6,100) over six months in 2005 prices. Direct costs were estimated at euro 1,900 (euro 1,700-2,200), 35% of total costs, and indirect costs at euro 3,600 (euro 3,100-4,100), 65% of total costs. The cost for antidepressants represented only 4% of the total costs. We conclude that the burden of depression is high, both to the individual as well as to wider society, and there seems to be a particular need for therapies that have the potential to improve productivity in depressed patients.
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Affiliation(s)
- P Sobocki
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
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Sobocki P, Ekman M, Agren H, Krakau I, Runeson B, Mårtensson B, Jönsson B. Health-related quality of life measured with EQ-5D in patients treated for depression in primary care. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2007; 10:153-60. [PMID: 17391424 DOI: 10.1111/j.1524-4733.2006.00162.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE The objective of the present study was to assess the impact of depression on patients' health-related quality of life (HRQL) with the EQ-5D instrument over 6 months while on antidepressant treatment. METHODS A total of 447 patients were recruited at 56 primary care centers to this naturalistic longitudinal observational study. Patients older than 18 years with depressive symptoms, and who initiated an antidepressant therapy because of depression were included in the study. Data on patients' sociodemographics, daily activity, and quality of life (EQ-5D) were collected using questionnaires completed during outpatient general practitioner visits for a follow-up period of 6 months. RESULTS The mean EQ-5D utility score at baseline was 0.47 (0.44-0.49). Milder cases of depression reported a health utility of 0.60, whereas moderately and severely depressed patients reported utility values of 0.46 and 0.27, respectively (P < 0.01). At end of follow up the average utility was 0.69 (0.67-0.72), corresponding to an increase of 0.23 over 6 months (P < 0.01). Regression analyses showed that, all else equal, patients who were on sick leave were associated with 10% lower utility. CONCLUSIONS Depression has a substantial impact on HRQL. Our results indicate that treatments for depression are associated with significant improvement in EQ-5D index score over a course of 6 months. Self-reported patient valuations are important outcomes for cost-utility analysis of new treatments for depression and the present study provides important evidence for future economic evaluations.
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Dueñas HJ, Dwight T, McBride ME, Brnabic AJM, Semper LA, Holmgren D, Miranda-Scippa AMA, Rincón HG, Aguilera H, Vargas A. Effectiveness of antidepressants in the treatment of major depressive disorder in Latin America. Int J Psychiatry Clin Pract 2007; 11:129-39. [PMID: 24937558 DOI: 10.1080/13651500600969129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective. Painful physical symptoms occur frequently in patients with major depressive disorder (MDD), and although numerous studies report the effect of antidepressants on emotional aspects of depression, few focus on their effect on physical symptoms. This observational study was conducted, in a clinical practice setting, to determine antidepressant treatment decisions and their outcome on the physical and emotional symptoms of MDD. Methods. Patients with a mean score ≥2 for pain-related items on the Somatic Symptom Inventory (SSI) were classified with painful physical symptoms (PPS +) and differentiated from the remaining patients (PPS -). Severity of depression and physical pain were determined using the 17-item Hamilton Depression Rating Scale (HAMD17) and Clinical Global Impressions of Severity Scale (CGI-S), and Visual Analog Scale (VAS), respectively. Results. At baseline, 72.6% of patients were PPS+. Compared to PPS- patients, PPS +patients were, on average, significantly more depressed at baseline (mean difference [95% CI]: HAMD17 4.6 [3.6, 5.5] and CGI-S 0.3 [0.2, 0.4]; all p<0.0001), and remained more depressed and in greater pain at endpoint (HAMD17p=0.0074, CGI-S P =0.0151, and VAS P <0.0001). In addition, fewer PPS+ patients (65.8%) achieved remission (total HAMD17≤7) compared to PPS- patients (74.6%, P =0.0180). Conclusions. Painful physical symptoms are prevalent in MDD patients, highlighting the importance of addressing both the physical and emotional symptoms of depression.
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