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Differences in Medication Adherence and Healthcare Resource Utilization Patterns

Older versus Newer Antidepressant Agents in Patients with Depression and/or Anxiety Disorders

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Abstract

Background: Given the number of antidepressants available and their rising costs, healthcare payers have initiated restrictive reimbursement policies for newer antidepressants, without consideration for differences in their effectiveness or tolerability.

Objective: The objective of this study was to comprehensively compare medication adherence rates and associated healthcare utilization costs for patients using later-generation versus earlier-generation antidepressants in a managed care setting. Antidepressants launched after 2002 were deemed third-generation antidepressants, while antidepressants available prior to 2002 were deemed first-generation (TCAs and MAOIs) and second-generation (serotonin and noradrena-line [norepinephrine]-dopamine reuptake inhibitors).

Study design: Retrospective database analysis using medical and pharmacy data from over 75 managed care plans covering 55 million lives.

Setting/patients: All patients receiving an antidepressant between 1 January 2002 and 30 September 2004 were identified. The index date for patients was the date of their first antidepressant prescription within this time period. Patients had to (i) have a diagnosis of depression or anxiety disorder, or depression and anxiety disorder within 6 months prior to or 30 days after their index prescription; (ii) be at least 18 years of age, without having taken antidepressant therapy for 6 months prior to their index date; and (iii) be continuously eligible for 6 months prior to their index date and during their 6-month follow-up period. Patients were excluded if they had a diagnosis of psychosis-related disease, Alzheimer’s or Parkinson’s disease, or were initiated on psychosis-related medications.

Intervention/main outcome measure: Patients meeting selection criteria were followed for 6 months to assess rates of antidepressant adherence, therapy change rates and medical healthcare costs.

Results: Study population: A total of 266 665 patients met the study criteria. Approximately 66% were female, with a mean age of 39 years. About 63% had a diagnosis of depression, 31% had an anxiety disorder diagnosis and 6% had diagnoses for both an anxiety disorder and depression. Therapy change: Therapy change within 6 months occurred in 18% of patients receiving third-generation agents compared with 21% and 40% for second- and first-generation agents, respectively. The odds of a therapy change were significantly lower with third-generation antidepressants compared with both older agent cohorts.

Adherence: Of patients receiving third-generation antidepressants, 33.6% were adherent compared with 29.3% and 12.4% of patients receiving second- and first-generation antidepressants, respectively. Newer agents also had better adherence rates across all diagnostic cohorts. After adjusting for baseline differences, the odds of being adherent to therapy were significantly lower for those taking second- and first-generation agents versus newer antidepressants. Among the newer agents, the proportion of patients adherent to their therapy was: venlafaxine extended release 38%, paroxetine controlled release (CR) 35%, escitalopram 34%, duloxetine 32% and bupropion extended release (XL) 31%.

Healthcare utilization: Of the patients taking older antidepressants, 13% (second generation) and 21% (first generation) were hospitalized at least once for any reason compared with 12% of patients taking newer agents. Overall, the odds of all-cause hospitalization within 6 months of therapy initiation were significantly higher for patients taking older antidepressants. Among the newer agents, hospitalization rates ranged from 15.9% for duloxetine to 12.5% for paroxetine CR and bupropion XL. The unadjusted 6-month total medical costs (not including pharmacy costs) per patient were $US3514 for second-generation, $US5744 forfirst-generation and $US3284 for newer antidepressants. After controlling for baseline differences, patients receiving second- and first-generation antidepressants incurred 12% and 44% higher costs, respectively. The unadjusted 6-month medical costs for the newer agents ranged from $US2715 for paroxetine CR to SUS6042 for duloxetine.

Conclusion: The results of this study provide essential information for healthcare decision makers about the potential advantages of newer generation antidepressants versus older generation antidepressants, as well as the differences between the specific newer agents, with respect to improved rates of adherence and therapy change, reduced hospitalizations and healthcare costs.

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Acknowledgements

This study was supported by a Collaborative Research Grant from GlaxoSmithKline. Management of the study, data analysis and interpretation were conducted by Dr Sheehan, and Dr Eaddy and his team at Xcenda, independent of the funding source. Mr Krulewicz, Dr Kraus and Dr Carpenter, employees of GlaxoSmithKline, participated in the study design and in the review of the manuscript. Dr Sheehan has worked, on a contractual basis, as a consultant to Xcenda and to GlaxoSmithKline. He received an honorarium from Xcenda for his consulting work on this study. He has received three grants for clinical trials through the University of South Florida from GlaxoSmithKline over the past 5 years. Dr Keene has worked, on a contractual basis, as a consultant to Xcenda. He received an honorarium from Xcenda for his consulting work on this study. Dr Eaddy is an employee of Xcenda. Xcenda provides consulting services to GlaxoSmithKline on a contractual basis. Mr Krulewicz and Dr Carpenter own stock and/or options in GlaxoSmithKline. In addition to Dr Eaddy, the Xcenda team included: Timothy S. Regan, RPh, CPh, research design and manuscript review; Anuprita Patkar, PhD, research design and database analysis; Anna D’Souza, PhD, database analysis and manuscript preparation; and Amy L. Grabowski, study management and manuscript preparation.

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Authors and Affiliations

  1. University of South Florida College of Medicine, Tampa, Florida, USA

    David V. Sheehan

  2. Medco Health Solutions, Franklin Lakes, New Jersey, USA

    Matthew S. Keene

  3. Xcenda, 4114 Woodlands Parkway, Suite 500, Palm Harbor, Florida, 34685, USA

    Michael Eaddy

  4. Neurosciences Medicines Development Center, Clinical Psychiatry North America, GlaxoSmithKline, King of Prussia, Pennsylvania, USA

    Stan Krulewicz

  5. Neurosciences Medicines Development Center, GlaxoSmithKline, Research Triangle Park, North Carolina, USA

    John E. Kraus

  6. Psychiatry Discovery Medicine, GlaxoSmithKline, King of Prussia, Pennsylvania, USA

    David J. Carpenter

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  1. David V. Sheehan
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  2. Matthew S. Keene
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  3. Michael Eaddy
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  4. Stan Krulewicz
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  6. David J. Carpenter
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Correspondence to Michael Eaddy.

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Sheehan, D.V., Keene, M.S., Eaddy, M. et al. Differences in Medication Adherence and Healthcare Resource Utilization Patterns. CNS Drugs 22, 963–973 (2008). https://doi.org/10.2165/00023210-200822110-00005

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