title: A budget-impact and cost-effectiveness model for second-line treatment of major depression.
abstract: BACKGROUND
  Depressed patients who initially fail to achieve remission when placed on a selective serotonin reuptake inhibitor (SSRI) may require a second treatment.
  
  
  OBJECTIVE
  The purpose of this study was to evaluate the effectiveness, cost, cost-effectiveness, and budget impact of second-line pharmacologic treatment for major depressive disorder (MDD).
  
  
  METHODS
  A cost-effectiveness analysis was conducted to evaluate second-line therapies (citalopram, escitalopram, fluoxetine, paroxetine, paroxetine controlled release [CR], sertraline, and venlafaxine extended release [XR]) for the treatment of depression. Effectiveness data were obtained from published clinical studies. The primary outcome was remission defined as a score of 7 or less on the Hamilton Rating Scale for Depression (HAM-D) or a score of 10 or less on the montgomery-Asberg Depression Rating Scale (MADRS) depression rating scales. The wholesale acquisition cost (WAC) for medications and medical treatment costs for depression were included. The perspective was derived from a managed care organization (MCO) with 500,000 members, a 1.9% annual incidence of depression, and treatment duration of 6 months. Assumptions included: second-line treatment is not as effective as first-line treatment, WAC price reflects MCO costs, and side effects were identical. Sensitivity analyses were conducted to determine variables that influenced the results.
  
  
  RESULTS
  Second-line remission rates were 20.4% for venlafaxine XR, 16.9% for sertraline, 16.4% for escitalopram, 15.1% for generic SSRIs (weighted average), and 13.6% for paroxetine CR. Pharmacy costs ranged from $163 for generic SSRIs to $319 for venlafaxine SR. Total cost per patient achieving remission was $14,275 for venlafaxine SR, followed by $16,100 for escitalopram. The incremental cost-effectiveness ratio (ICER) for venlafaxine SR compared with generic SSRIs was $2,073 per patient achieving remission, followed by escitalopram with an ICER of $3,566. The model was most sensitive to other therapies.
  
  
  CONCLUSIONS
  This analysis suggests that second-line treatment of depression with venlafaxine XR may result in more patients achieving remission with an ICER that is favorable to other therapies.
authors.affiliation: Center for Health Outcomes and Pharmacoeconomic Research, University of Arizona College of Pharmacy, Tucson, AZ 85721, USA. malone@pharmacy.arizona.edu
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Malone
mesh_terms: D018687:Antidepressive Agents, Second-Generation / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003865:Major Depressive Disorder / Q000188:drug therapy* / Q000191:economics*; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008329:Managed Care Programs; D018803:Models, Economic; D016032:Randomized Controlled Trials as Topic; D012074:Remission Induction; D017367:Selective Serotonin Reuptake Inhibitors / Q000191:economics / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D018687:Antidepressive Agents, Second-Generation; D017367:Selective Serotonin Reuptake Inhibitors