Timothy R. Hylan

Recovery from depression, work productivity, and health care costs among primary care patients

We describe a secondary analysis of data from a randomized trial conducted at seven primary care clinics of a Seattle area HMO. Adults with major depression (n=290) beginning antidepressant treatment completed structured interviews at baseline, 1, 3, 6, 9, 12, 18, and 24 months. Interviews examined clinical outcomes (Hamilton Depression Rating Scale and depression module of the Structured Clinical Interview for DSM-IIIR), employment status, and work days missed due to illness. Medical comorbidity was assessed using computerized pharmacy data, and medical costs were assessed using the HMOs computerized accounting data. Using data from the 12-month assessment, patients were classified as remitted (41%), improved but not remitted (47%), and persistently depressed (12%). After adjustment for depression severity and medical comorbidity at baseline, patients with greater clinical improvement were more likely to maintain paid employment (P=.007) and reported fewer days missed from work due to illness (P<.001). Patients with better 12-month clinical outcomes had marginally lower health care costs during the second year of follow-up (P=.06). We conclude that recovery from depression is associated with significant reductions in work disability and possible reductions in health care costs. Although observational data cannot definitively prove any causal relationships, these longitudinal results strengthen previous findings regarding the economic burden of depression on employers and health insurers.

Longitudinal patterns of antidepressant prescribing in primary care in the UK: comparison with treatment guidelines

The objective of this study was to determine whether patients beginning therapy on the most common tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) differed in their likelihood of having antidepressant treatment that was consistent with recommended treatment guidelines in the UK. An analytical file constructed from a large general practitioner medical records database (DIN-LINK) from the UK for the years 1992-97 was constructed. A total of 16 204 patients with a new episode of antidepressant therapy who initiated therapy on one of the most often prescribed TCAs (amitriptyline, dothiepin, imipramine and lofepramine) or SSRIs (fluoxetine, paroxetine and sertraline) were analysed. A dichotomous measure was defined to indicate whether subjects were prescribed at least 120 days of antidepressant therapy at an adequate average daily dose within the first 6 months after initiation of therapy. Only 6.0% of patients initiating therapy on aTCA and 32.9% of patients initiating therapy on a SSRI were prescribed antidepressant treatment that was consistent with treatment guidelines. After controlling for observable characteristics, patients who initiated therapy on a SSRI were much more likely (odds ratio=7.473, p<0.001) to have a prescribed average daily dose and duration consistent with recommended treatment guidelines within the first 6 months of initiating therapy than were patients who initiated therapy on a TCA. These findings suggest that initial antidepressant selection is an important determinant of whether the subsequent course of treatment is consistent with current national guidelines for the treatment of depression in the UK.

Antidepressant selection and use and healthcare expenditures. An empirical approach.

SummaryThe purpose of this study was to evaluate whether 1−year total healthcare expenditures differed between patients who initiated therapy on a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) after controlling for initial antidepressant selection and antidepressant use pattern. A retrospective claims database covering a privately insured population in the US was used. Patients who initiated therapy in the outpatient setting (primary care or psychiatrist) were considered. Two—stage sample selection models were estimated that included controls for initial antidepressant selection and use pattern. The analyses indicated that: (i) self—selection due to initial antidepressant selection was a statistically significant determinant of expenditures for patients who initiated therapy on a TCA but not an SSRI; (ii) after controlling for initial antidepressant selection, antidepressant use pattern was a statistically significant and positive determinant of expenditures for both TCA and SSRI patients; and (iii) after controlling for initial antidepressant selection and use pattern, 1−year total direct healthcare expenditures were significantly lower for patients who initiated therapy on an SSRI than for patients who initiated therapy on a TCA.

Health economic evaluations of antidepressants: A review

In an era of constrained health care financing, clinicians are increasingly faced with considering the economic consequences in addition to the clinical outcomes associated with initiating a patient on antidepressant therapy. This has increased the demand for health economic studies comparing antidepressant use and associated health care expenditures in clinical practice. These health economics studies have used methods ranging from clinical trials to other types of analyses including prospective naturalistic trials or retrospective studies which may be less familiar to clinicians. Prospective and retrospective health economics studies performed in clinical practice complement the experience gained from clinical trials in assessing antidepressant use and economic outcomes in light of patient and provider behavior within the usual care environment of a complex health care system. Broadly considered, health economic studies of antidepressants have consistently found differences in clinical practice between the tricyclic antidepressants (TCAs) and the selective serotonin reuptake inhibitors (SSRIs) as well as among the SSRIs. These differences relate to the pattern and duration of antidepressant use as well as total direct health care expenditures. Future health economic research studies in clinical practice should focus on the economic consequences of long‐term antidepressant use as well as the impact of antidepressant use on indirect costs such as productivity and absenteeism. Depression and Anxiety 7:53–64, 1998.

A framework for drug utilization evaluation in depression: insights from outcomes research.

BACKGROUND Drug utilization evaluation (DUE) offers the prospect of improving the quality of care in depression by focusing on drug-related problems (DRPs). Outcomes research in depression can provide a basis on which to address difficulties in implementing DUE programs in the outpatient environment of managed care. OBJECTIVE The purpose of this paper is to facilitate the development of a drug utilization evaluation program for depressed patients receiving care in an outpatient environment. METHODS The literature was reviewed in the area of depression treatment, drug-related problems, and current outcomes research. This information was synthesized into a framework with potential DUE criteria. CONCLUSION The quality of care for depression can be improved if these efforts are focused on solving DRPs. Outcomes research findings may be used as the basis for developing DUE criteria and as a first step in selecting and targeting interventions.

Prescribing of Selective Serotonin Reuptake Inhibitors, Anxiolytics, and Sedative-Hypnotics by General Practitioners in the Netherlands: A Multivariate Analysis

A study of the prescribing of anxiolytics and sedative-hypnotics and the occurrence of anxiety or sleep disorders before and after the initiation of selective serotonin reuptake inhibitor (SSRI) therapy may provide insight into differences in individual SSRIs. The purpose of our study was to evaluate whether and in what way the likelihood of being prescribed an anxiolytic or sedative-hypnotic or receiving a diagnosis of an anxiety or sleep disorder differed in patients prescribed either fluoxetine or paroxetine by a general practitioner (GP) in the Netherlands, where these two agents are the most commonly prescribed SSRIs. Episodes of SSRI treatment were constructed from a recently available GP database in the Netherlands. Logistic regression analysis was used to determine whether, after controlling for other observable factors, the receipt of paroxetine or fluoxetine was a statistically significant determinant for receipt of an anxiolytic or sedative-hypnotic or a diagnosis of an anxiety or sleep disorder. We found that patients who were prescribed fluoxetine as their index drug were less likely to receive a concomitant sedative-hypnotic on their index date compared with patients receiving paroxetine. After controlling for other observable factors, such as use of anxiolytics and sedative-hypnotics before SSRI therapy or on the index date or the existence of comorbid anxiety or sleep disorders, patients starting fluoxetine therapy were no more likely than patients starting paroxetine therapy to receive an anxiolytic or sedative-hypnotic or a diagnosis of an anxiety or sleep disorder during the 60-day post period. The likelihood of a patients being diagnosed with or receiving a prescription for an anxiety or sleep disorder does not appear to be a differentiating factor between the prescribing of fluoxetine or paroxetine by GPs in the Netherlands.

SSRI antidepressant selection and concomitant prescribing of anxiolytics and sedative-hypnotics: evidence from primary care in the United Kingdom

SummaryConcomitant prescribing of benzodiazepines during antidepressant therapy may increase patient exposure to undesirable side-effects, increase the total cost of therapy, and reflect impairment of health-related quality of life. This study examines concomitant benzodiazepine prescriptions after initiation of therapy on three commonly prescribed SSRIs: fluoxetine, paroxetine, and sertraline. A retrospective analysis of prescribing behaviours of physicians from general practices in the United Kingdom utilises a statistical model that addresses the non-negative values and skewed distribution found in count data measures of benzodiazepine prescriptions. An adjustment is made for potential sample selection bias that might result from factors correlated with both antidepressant choice and benzodiazepine prescribing. The distribution of patients receiving benzodiazepine prescriptions across drug cohorts is: 5.4% of the fluoxetine cohort; 6.4% of paroxetine patients; and 4.3% of sertraline patients. The main ...

Antidepressant use and resource utilization in the general practitioner setting in The Netherlands

Objective—To assess antidepressant use and resource utilization in the general practitioner (GP) setting in the Netherlands following initiation of antidepressant therapy.

Institutional change and invariance of behaviour in Major League Baseball

The invariance interpretation of the Coase Theorem is examined using the mobility behaviour of all offensive players (hitters) in Major League Baseball (MLB) who played from 1949 to 1992. Results indicate that while the institution of the rookie draft did not affect the mobility of players, the mobility of players was altered under free agency. In addition, the period of free agency witnessed mobility behaviours of veteran players which was unlike that mobility under the guidance of owners.

Antidepressant Use and Clinical and Economic Outcomes in a Primary Care Psychiatry Center in Spain

In the context of managed care, cost-containment strategies lead to the establishment of procedures aimed at reducing the expense of medication.