Economic appraisal of citalopram in the management of single-episode depression.
A retrospective intent-to-treat analysis (N = 1,339) was conducted to discern the natural course of antidepressant use and direct health service expenditures for the treatment of single-episode depression (DSM-IV code 296.20) among patients initiating antidepressant pharmacotherapy with either a tricyclic antidepressant (TCA) (amitriptyline, N = 237) or a selective serotonin reuptake inhibitor (SSRI) (citalopram, N = 71; fluoxetine, N = 411; paroxetine, N = 334; or sertraline, N = 286). Data were derived from the computer archive of a network-model health maintenance organization for the period of January 1, 1996, through April 30, 1999. Comparisons at the end of the 6-month post-period (180 days) were undertaken between cohorts initiating antidepressant pharmacotherapy with citalopram and each SSRI or TCA. Consistent with the intent-to-treat design, all accrued health service expenditures were assigned to the pharmacotherapeutic option initially prescribed. Multivariate models were adjusted for patient's age, gender, number of concomitant disease state processes, use of health services in the 6-month time frame (180 days) before initiating antidepressant pharmacotherapy, specialty of physician recording a diagnosis of single-episode depression, and the presence or absence of a previous diagnosis of single-episode depression and receipt of antidepressant pharmacotherapy. Patients initiating antidepressant pharmacotherapy with citalopram were far more likely to (1) have been diagnosed by a psychiatrist (37%; p < or = 0.05); (2) continue with the original pharmacotherapeutic option (79%) compared with patients originally prescribed amitriptyline (51%; chi2 = 17.29, df = 1, p < or = 0.05) or sertraline (65%; chi2 = 36.91, df = 1, p < or = 0.05); no significant difference was found compared with patients initiating antidepressant pharmacotherapy with paroxetine (72%; p = not significant [NS]) or fluoxetine (83%; p = NS); (3) obtain 90 days or more of antidepressant pharmacotherapy (86%) compared with those prescribed amitriptyline (69%; chi2 = 8.09, df = 1, p < or = 0.05); no significant difference was found compared with sertraline (77%), paroxetine (81%), or fluoxetine (84%); and (4) obtain 6 months (180 days) of antidepressant pharmacotherapy (68%) compared with those prescribed amitriptyline (39%; chi2 = 18.26, df = 1, p < or = 0.05) or sertraline (51%; chi2 = 6.02, df = 1, p < or = 0.05); no significant difference was found compared with paroxetine (56%) or fluoxetine (59%). Receipt of amitriptyline or sertraline as initial medication was associated with a per capita increase (p < or = 0.05) in health service utilization (17% and 9%, respectively) relative to citalopram. No significant difference (p > 0.05) in health service utilization was discerned between citalopram and either fluoxetine or paroxetine. Multivariate models adjusted for nonrandom assignment to the initial pharmacotherapeutic option confirmed these findings. Further research over a longer time course is warranted.
Sclar
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Pharmacoeconomics and Pharmacoepidemiology Research Unit, College of Pharmacy, Washington State University, Pullman 99164-6510, USA. sclar@mail.wsu.edu
Skaer
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Robison
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Galin
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RS
D000328:Adult; D000639:Amitriptyline / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D018687:Antidepressive Agents, Second-Generation / Q000009:adverse effects / Q000191:economics* / Q000627:therapeutic use; D000929:Antidepressive Agents, Tricyclic / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003866:Depressive Disorder / Q000188:drug therapy / Q000191:economics* / Q000523:psychology; D005260:Female; D005473:Fluoxetine / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D006279:Health Maintenance Organizations / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D017374:Paroxetine / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use; D010348:Patient Care Team / Q000191:economics; D012189:Retrospective Studies; D020280:Sertraline / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use
D018687:Antidepressive Agents, Second-Generation; D000929:Antidepressive Agents, Tricyclic; D005473:Fluoxetine; D000639:Amitriptyline; D017374:Paroxetine; D020280:Sertraline