Assessment of clinical guidelines for continuation treatment in major depression.
OBJECTIVE
The primary objective of this study was to assess the appropriateness of the existing Dutch clinical guidelines for the treatment of depression from a health-economic perspective. The existing guidelines recommend continuation treatment for a period up to 9 months.


METHODS
The assessment was based on a Markov model using decision-analytic techniques. For this analysis we defined six mutually exclusive states defined by the existence of depression and type of treatment. The outcomes for the model were defined as: time without depression (TWD), quality-adjusted life years (QALYs), direct medical costs, and cost of lost productivity. The primary perspective of the study was that of the third-party payer, while the secondary perspective was that of the society in 1999. The probabilities of clinical events and therapeutic choices as well as the utilities were based on published literature. The medical resource use related to each state was abstracted from published literature and expert opinion. The associated 1999 unit costs of the used medical resources were derived from official Dutch tariff lists of allowable reimbursements. Indirect costs in this model were based on lost productivity only.


RESULTS
The results of the primary analysis showed that the use of the guidelines is not cost-effective. Continuation treatment for a period of 9 months increases the total direct medical costs (NLG 1276 vs. NLG 474), decreases the costs resulting from lost productivity (NLG 304 vs. NLG 909), increases total costs (NLG 1580 vs. NLG 1383) and increases TWD (96.9% vs. 86.4%). However, continuation treatment does not change the utility outcomes (0.60 vs. 0.61 QALYs) for both treatment strategies. Hence continuation treatment is not cost-effective from either a third-party payer perspective or a societal perspective. A scenario analysis showed that an extension of the continuation treatment to maintenance treatment might result in a favorable cost-effectiveness outcome of the treatment guideline.


CONCLUSIONS
In conclusion, based on the assumptions used in the model, the current Dutch treatment guidelines for depression are only appropriate from a health-economic perspective if continuation treatment is extended to maintenance treatment.
Nuijten
M J
MJ
MEDTAP International, Dorpsstraat 75, 1526 LG Jisp, Amsterdam, The Netherlands. nuijtenmedtap@compuserve.com
D000929:Antidepressive Agents, Tricyclic / Q000191:economics / Q000627:therapeutic use*; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003865:Major Depressive Disorder / Q000188:drug therapy* / Q000191:economics*; D016527:Drug Costs / Q000706:statistics & numerical data; D017850:Economics, Pharmaceutical; D004526:Efficiency; D017050:Episode of Care; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000191:economics; D006801:Humans; D007358:Insurance, Psychiatric; D008134:Long-Term Care / Q000191:economics; D008390:Markov Chains; D009426:Netherlands; D010349:Patient Compliance; D017410:Practice Guidelines as Topic; D019057:Quality-Adjusted Life Years; D017367:Selective Serotonin Reuptake Inhibitors / Q000191:economics / Q000627:therapeutic use*
D000929:Antidepressive Agents, Tricyclic; D017367:Selective Serotonin Reuptake Inhibitors