A Budget-Impact and Cost-Effectiveness Model for Second-Line Treatment of Major Depression

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. CONCLUSION: 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.