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Escitalopram and Duloxetine in Major Depressive Disorder

A Pharmacoeconomic Comparison Using UK Cost Data

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Abstract

Background: Selective serotonin reuptake inhibitors (SSRIs) and serotoninnoradrenaline reuptake inhibitors (SNRIs) are approved for the treatment of major depressive disorder (MDD). The allosteric SSRI escitalopram has been shown to be at least as clinically effective as the SNRIs venlafaxine and duloxetine in MDD, with a better tolerability profile. In addition, escitalopram has been shown to be cost saving compared with venlafaxine.

Objective: To evaluate the cost effectiveness of escitalopram versus duloxetine in the treatment of MDD, and to identify key cost drivers.

Methods: The pharmacoeconomic evaluation was conducted alongside a 24-week, double-blind, multinational randomized study (escitalopram 20 mg/day and duloxetine 60 mg/day) in outpatients with MDD, aged 18–65 years, with Montgomery-Åsberg Depression Rating Scale (MADRS) score ≥26 and Clinical Global Impression Severity (CGI-S) score ≥4, and baseline duration of the current depressive episode of 12 weeks to 1 year.

The analysis was conducted on the full analysis set (FAS), which included all patients with ≥1 valid post-baseline health economic assessment. Effectiveness outcomes of the cost-effectiveness analyses (CEA) included the change in Sheehan Disability Scale (SDS) score (primary CEA), treatment response (MADRS score decrease ≥50%) and remission (MADRS score ≤12) rates at week 24. Cost outcomes were assessed from the societal perspective. Healthcare resource use and sick leave were evaluated using a health economic assessment questionnaire. Unit costs of healthcare services were obtained from standard UK sources (£, year 2006 values).

Results: Over the total 24-week study period, escitalopram was associated with significant cost savings compared with duloxetine (total per-patient monthly cost £188 vs £334, respectively). In the primary CEA, escitalopram dominated duloxetine (i.e. was more effective on the disability scale and less costly). Treatment with escitalopram resulted in significantly lower mean sick leave duration per patient over 24 weeks than duloxetine (30.7 days vs 62.2 days).

In multivariate analyses, escitalopram as a treatment choice was associated with a 54% reduction in sick leave duration (p < 0.001). Treatment with escitalopram also resulted in 49% lower total costs than treatment with duloxetine (p = 0.002). Absenteeism accounted for about two-thirds of the overall cost. Early clinical improvement (mean change in MADRS total score, response and remission) had an independent significant impact on the sick leave duration, after controlling for key co-variates.

Conclusions: Escitalopram was associated with significantly lower duration of sick leave and significant savings in the total cost compared with duloxetine; it dominated duloxetine when effectiveness was assessed on the SDS scale. Indirect costs due to sick leave accounted for the most substantial portion of the total cost and should, therefore, be an important consideration when pharmacoeconomic comparisons between treatments are made from the societal perspective. The link between decrease in absenteeism and early (8-week) clinical improvement suggested in the additional analyses may explain the reduced sick leave observed with escitalopram, given its superior short-term efficacy compared with duloxetine (demonstrated in the underlying clinical trial).

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Notes

  1. The use of trade names is for product identification purposes only and does not imply endorsement.

  2. For a visit to a psychiatrist, the unit cost was lowered to £123 excluding qualification considerations. For other specialists, unit costs of visits were lowered to estimates corresponding to follow-up visits (vs first-attendance unit cost applied in the base case) and amounted to £103 (cardiologist), £64 (dermatologist), £69 (ENT specialist) and £96 (gastroenterologist).

  3. Although the numerical difference between treatment groups is high, it did not reach statistical significance. This is probably due to the small number of patients in comparison groups (e.g. at week 24, only seven patients with sick leave were identified in the escitalopram group).

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Acknowledgements

This study was supported by funding from H. Lundbeck A/S.

The authors would like to thank Natalie Barker of Wolters Kluwer Health for her assistance with writing the manuscript.

Alan G. Wade has received honoraria from H. Lundbeck A/S and grants from H. Lundbeck A/S for clinical trial participation. He has also acted for H. Lundbeck A/S and Eli Lilly as a researcher and member of advisory boards.

José-Luis Fernández has received consultancy fees from H. Lundbeck A/S for pharmaceutical research.

Clément François, Karina Hansen, Natalya Danchenko and Nicolas Despiegel are employees of H. Lundbeck A/S.

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Authors and Affiliations

  1. CPS Research, Glasgow, UK

    Alan G. Wade

  2. London School of Economics, London, UK

    José-Luis Fernández

  3. H. Lundbeck A/S, Paris, France

    Clément François, Karina Hansen, Natalya Danchenko & Nicolas Despiege

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  1. Alan G. Wade
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Correspondence to Clément François.

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Wade, A.G., Fernández, JL., François, C. et al. Escitalopram and Duloxetine in Major Depressive Disorder. Pharmacoeconomics 26, 969–981 (2008). https://doi.org/10.2165/00019053-200826110-00008

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