Elsevier

Journal of Psychiatric Research

Volume 63, April 2015, Pages 123-131
Journal of Psychiatric Research

Depression and pain: An appraisal of cost effectiveness and cost utility of antidepressants

https://doi.org/10.1016/j.jpsychires.2015.01.019Get rights and content

Highlights

  • In this study, SSRIs were found to dominate SNRIs in both the cost-effectiveness and cost-utility.

  • For patients without painful physical symptoms (PPS), SSRIs were likely to be the cost-effective option.

  • For those with PPS, the cost-utility advantage for SSRIs over TCAs varied with threshold willingness-to-pay levels.

  • Comorbid PPS may be considered an effect modifier of the economic evaluation results for SSRIs versus TCAs.

Abstract

Background

Although depression and chronic pain frequently co-occur, there is a lack of clarity in the literature regarding the cost-effectiveness and cost-utility of antidepressants in the presence of these two conditions. From the perspective of healthcare provider, the current study aims to compare the cost-effectiveness and cost-utility of antidepressants in a national cohort of depressed patients with and without comorbid pain conditions.

Methods

Adult patients prescribed with antidepressants for depression were identified from the National Health Insurance Research Database in Taiwan (n = 96,501). By using remission as effectiveness measure and quality-adjusted life years (QALYs) as utility measure, the cost-effectiveness and cost-utility were compared across selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), as well as by the presence of comorbid painful physical symptoms (PPS).

Results

SSRIs dominated SNRIs in both the cost-effectiveness and cost-utility regardless of comorbid PPS. In comparison with TCAs, SSRIs were likely to be the cost-effective option for patients without PPS. In patients with PPS, the cost-utility advantage for SSRIs over TCAs varied with threshold willingness-to-pay levels. Comorbid PPS may be considered an effect modifier of the cost-utility comparisons between SSRIs and TCAs.

Conclusions

For depressed patients without PPS, SSRIs are likely to be cost-effective in improving remission rates and QALYs compared to TCAs and SNRIs. However, to improve cost-utility in those with comorbid PPS, people need to choose between SSRIs and TCAs according to threshold willingness-to-pay levels. Future research is warranted to clarify the impacts of different pain conditions on the economic evaluations of pharmacological treatments in patients with depression.

Introduction

Painful physical symptoms (PPS) have been shown to precede the onset of a new depressive episode (Barry et al., 2013), and to contribute to prolongation of the duration of depressive mood (Ohayon and Schatzberg, 2003). In a community survey, the severity of PPS, including headache, pain in the abdomen, back pain and other musculoskeletal pains, has been found to correlate with the severity of depressive symptoms. Presence of PPS deteriorates physical, occupational and socio-professional activities in patients with depression (Ohayon and Schatzberg, 2010). With the evidence that comorbid PPS may be associated with a poor response to antidepressants (Bair et al., 2004, Carter et al., 2012, Kroenke et al., 2008, Leuchter et al., 2010), and with increased healthcare costs (Gameroff and Olfson, 2006, Greenberg et al., 2003, Pan et al., 2013a), the results of cost effectiveness analysis (CEA) comparing antidepressant treatments may be influenced in the presence of comorbid PPS.

Depression and pain have been reported to be among the most burdensome diseases globally (Vos et al., 2012). These two conditions contribute to the highest loss of quality-adjusted life years (QALYs) (Subramaniam et al., 2013). In patients with depression, the severity of PPS has been shown to be associated with disability (Ohayon and Schatzberg, 2010) and considered a strong predictor of impaired quality of life (Bair et al., 2004). Given the impacts of PPS on quality of life of depressed patients, a cost utility analysis (CUA) comparing antidepressants is wanted when presence of PPS is taken into consideration. In CEA, costs are considered alongside disease-specific outcomes, e.g., treatment response to antidepressants. This kind of economic evaluation is limited by the narrow focus on a single measure of effectiveness outcome. There can be difficulties in evaluating treatments that impact on more than one outcome, e.g., social functioning and quality of life. A CUA is similar to a CEA but it considers costs alongside a utility based outcome measure, usually QALYs. The advantage of CUA is that the results can be compared across different disease areas.

Although tricyclic antidepressants (TCAs) and serotonin norepinephrine reuptake inhibitors (SNRIs) were shown to be probably more effective than selective serotonin reuptake inhibitors (SSRIs) in reducing PPS (Bair et al., 2004, Peveler et al., 2006), results from other clinical trials revealed similar response rate and pain relief across antidepressant groups in patients with both depression and pain (Qaseem et al., 2008). Whether and how individual antidepressants differ in the effectiveness of depression treatment and pain relief remains to be determined. According to a previous review (Pan et al., 2012), most of the existent economic evaluations of antidepressants were based on modelling and relatively few CEA and CUA studies have been conducted with patients of depressive disorders in real-world settings (Hosak et al., 2000, Peveler et al., 2005, Serrano-Blanco et al., 2006a, Serrano-Blanco et al., 2006b, Serrano-Blanco et al., 2009). Among the economic evaluations addressing individual antidepressants in patients with selective pain disorders, a systematic review showed that even for duloxetine (a SNRI), no relevant cost or cost-effectiveness data could be identified in high quality studies (Lunn et al., 2014). In patients with depression and comorbid PPS, evidence regarding the cost-effectiveness (or cost-utility) comparisons across individual antidepressants remain wanting.

Therefore, from the perspective of healthcare providers, we conducted both CEA and CUA among individual antidepressants in the current study based on the National Health Insurance Research Database (NHIRD) records of the entire national assemblage of adult depressed patients in Taiwan. Because antidepressants might differ in their effects on the management of PPS, we hypothesise that results of CEA and CUA comparing antidepressant treatments differ by the presence of comorbid PPS. The objective was to compare the cost-effectiveness and cost-utility across antidepressant categories and to test whether and how the presence of PPS could affect the economic evaluations of antidepressants in a real-world setting.

Section snippets

Subjects

National Health Insurance (NHI) in Taiwan is a single-payer compulsory social insurance plan that centralises the disbursement of healthcare funds and guarantees equal access to healthcare for all citizens. The NHI system in Taiwan contains the NHIRD which consists of data characterising healthcare utilisation of insured residents, including expenditures, medical procedures/treatments, and basic characteristics of patients, providers and physicians. Subjects aged 18 or older meeting the

Study population

A total of 96,501 adult individuals met the inclusion criteria. The number of subjects with comorbid PPS was 77,067. Patients with PPS were older; they were more likely to be females and less likely to have newly-diagnosed depression. With regards to baseline healthcare utilisation, patients with PPS had higher use of outpatient services and higher baseline total healthcare costs than those without PPS (Table 1).

Cost and effectiveness outcome

In comparison with depressed patients without PPS, those with PPS were found to

Discussion

Based on a nationally representative sample in Taiwan, the current study provided data of the cost-effectiveness and cost-utility of SSRIs, SNRIs, and TCAs in depression with and without comorbid PPS. For depressed patients without PPS, SSRIs were likely to be the most cost-effective option in improving treatment-success rates and gained QALYs. However, for those with PPS, the cost-utility advantage of SSRIs over TCAs was equivocal considering the ICUR results which were much higher than those

Role of the funding source

This study was funded by a grant from Far Eastern Memorial Hospital, Taiwan (FEMH-97-C-022). The funding body played no roles in study design, analysis or interpretation of data in this paper.

Contributors

Author YP designed the study, analysed the data, managed the literature searches and wrote the first draft of the manuscript. Author CP and HC contributed to data analyses and interpretations of the results. Author KK contributed to the study design, as well as discussions of the results. All authors contributed to and approved the final manuscript.

Conflict of interest

None.

Acknowledgements

YJ Pan and CH Pan have contributed to this study equally as first author. This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health, Taiwan, and managed by National Health Research Institutes, Taiwan. The interpretation and conclusions contained herein do not represent those of Bureau of National Health Insurance, Department of Health or National Health Research Institutes.

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