title: Cost-Effective Drug Switch Options After Unsuccessful Treatment With an SSRI for Depression.
abstract: Multiple treatment options are available for patients who do not respond to initial treatment for major depressive disorder. Previous results show that bupropion, sertraline, and venlafaxine are comparable in terms of therapeutic effectiveness following unsuccessful treatment with citalopram. In this study, we extended these results by incorporating costs of treatment to determine if one option was more cost-effective relative to others.
  
  
  
  In the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial, 727 patients were randomly assigned to a switch drug treatment during level 2; 239 (33%) were assigned to bupropion, 238 (33%) to sertraline, and 250 (34%) to venlafaxine. For each study medication, the total costs included the costs of the medication, other concomitant medication and antidepressants, and health care facility utilization. Effectiveness was measured as remission and response. Cost-effectiveness was assessed as net health benefits. Stochastic analysis was performed by using the bootstrapping method.
  
  
  
  During level 2, mean medication costs were significantly higher for venlafaxine than for bupropion and sertraline ($968, $607, and $703, respectively). There were no significant differences among the switch medications in costs for other medications and health care facility utilization. Although the total costs were significantly different for the three medications (p=.025), none of the pairwise differences between medications were significant. Also, after jointly estimating costs and effects, the analyses found that net health benefits were not significantly different among the three drugs.
  
  
  
  After unsuccessful treatment with citalopram, the switch options of bupropion, sertraline, and venlafaxine were not significantly different from each other in terms of cost-effectiveness.
authors.affiliation: Dr. Singh, Dr. Brooks, Dr. Voorhees, Mr. Luther, and Dr. Wisniewski are with the Department of Epidemiology, and Ms. Potter and Dr. Roberts are with the Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (e-mail: ashimasingh7@gmail.com ).
authors.forename: Ashima
authors.initials: A
authors.lastname: Singh
authors.affiliation: Dr. Singh, Dr. Brooks, Dr. Voorhees, Mr. Luther, and Dr. Wisniewski are with the Department of Epidemiology, and Ms. Potter and Dr. Roberts are with the Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (e-mail: ashimasingh7@gmail.com ).
authors.forename: Maria M
authors.initials: MM
authors.lastname: Brooks
authors.affiliation: Dr. Singh, Dr. Brooks, Dr. Voorhees, Mr. Luther, and Dr. Wisniewski are with the Department of Epidemiology, and Ms. Potter and Dr. Roberts are with the Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (e-mail: ashimasingh7@gmail.com ).
authors.forename: Ronald E
authors.initials: RE
authors.lastname: Voorhees
authors.affiliation: Dr. Singh, Dr. Brooks, Dr. Voorhees, Mr. Luther, and Dr. Wisniewski are with the Department of Epidemiology, and Ms. Potter and Dr. Roberts are with the Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (e-mail: ashimasingh7@gmail.com ).
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Potter
authors.affiliation: Dr. Singh, Dr. Brooks, Dr. Voorhees, Mr. Luther, and Dr. Wisniewski are with the Department of Epidemiology, and Ms. Potter and Dr. Roberts are with the Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (e-mail: ashimasingh7@gmail.com ).
authors.forename: Mark S
authors.initials: MS
authors.lastname: Roberts
authors.affiliation: Dr. Singh, Dr. Brooks, Dr. Voorhees, Mr. Luther, and Dr. Wisniewski are with the Department of Epidemiology, and Ms. Potter and Dr. Roberts are with the Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (e-mail: ashimasingh7@gmail.com ).
authors.forename: James F
authors.initials: JF
authors.lastname: Luther
authors.affiliation: Dr. Singh, Dr. Brooks, Dr. Voorhees, Mr. Luther, and Dr. Wisniewski are with the Department of Epidemiology, and Ms. Potter and Dr. Roberts are with the Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (e-mail: ashimasingh7@gmail.com ).
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Wisniewski
mesh_terms: D000328:Adult; D016642:Bupropion / Q000191:economics / Q000494:pharmacology; D015283:Citalopram / Q000494:pharmacology; D003362:Cost-Benefit Analysis; D003865:Major Depressive Disorder / Q000188:drug therapy / Q000191:economics; D018765:Dopamine Uptake Inhibitors / Q000191:economics / Q000494:pharmacology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000191:economics; D017367:Selective Serotonin Reuptake Inhibitors / Q000191:economics / Q000494:pharmacology; D000068760:Serotonin and Noradrenaline Reuptake Inhibitors / Q000191:economics / Q000494:pharmacology; D020280:Sertraline / Q000191:economics / Q000494:pharmacology; D000069470:Venlafaxine Hydrochloride / Q000191:economics / Q000494:pharmacology
chemical_list: D016642:Bupropion; D015283:Citalopram; D018765:Dopamine Uptake Inhibitors; D017367:Selective Serotonin Reuptake Inhibitors; D000068760:Serotonin and Noradrenaline Reuptake Inhibitors; D020280:Sertraline; D000069470:Venlafaxine Hydrochloride
keywords: Cost-effectiveness analysis; Depression; Second-line antidepressants