Comparative Assessment of Adherence Measures and Resource Use in SSRI/SNRI-Treated Patients with Depression Using Second-Generation Antipsychotics or L-Methylfolate as Adjunctive Therapy
Comparative Assessment of Adherence Measures and Resource Use in SSRI/SNRI-Treated Patients with Depression Using Second-Generation Antipsychotics or L-Methylfolate as Adjunctive Therapy
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使用第二代抗精神病药物或 L-甲基叶酸作为辅助治疗的 SSRI/SNRI 治疗抑郁症患者的依从性测量和资源使用的比较评估
DOI：
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发表时间：
2014
影响因子：
--
通讯作者：
M. Thase
中科院分区：
文献类型：
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作者：
R. Wade;S. Kindermann;Q. Hou;M. Thase
背景：单一抗抑郁药物治疗仅能有效缓解约1/3的抑郁症患者，即使改用第二种抗抑郁药物，累积缓解率也只有50%-55%。这导致了人们对治疗难治性抑郁症的强化疗法的兴趣。目的：评估(A)选择性5-羟色胺再摄取抑制剂/选择性去甲肾上腺素再摄取抑制剂(SSRI/SNRI)与第二代非典型抗精神病药物(SGAs)或L-甲基叶酸联合应用时的依从性，以及(B)抑郁症特异性和总医疗保健成本，比较两种形式的强化疗法治疗抑郁症的效果。方法：在MarketScan数据库中对2006年1月1日至2009年12月31日(索引日期)期间被诊断为抑郁症并在药房申请SSRI/SNRI的患者，同时接受SGA或L-甲基叶酸强化治疗(强化日期)，并进行231d的随访。患者被排除在指数前90天内有任何抗抑郁药物或SGA的药房申请；在指数前6个月有L-甲基叶酸；指数日期年龄小于 18岁；或在指数前12个月内被诊断为怀孕、痴呆症、精神病相关精神障碍、阿尔茨海默氏症或帕金森氏病。采用倾向性评分匹配(3：1比例，非典型抗精神病药物与L-叶酸甲酯)选择最终研究队列，使用年龄、性别、合并症、SSRI/SNRI指数和SSRI/SNRI剂量的协变量。从增强日期开始衡量抗抑郁药物治疗的依从性，包括HEDIS(MHEDIS)AMM急性和慢性阶段测量的改进应用以及6个月的药物拥有率。卫生保健利用率和费用是在6个月的增强期后进行衡量的，其中包括总利用率和与抑郁症相关的利用率/费用。使用卡方检验对二元测量进行卡方检验，并对连续测量进行t检验，对紧密匹配的SGA和L-甲基叶酸增加的队列进行比较。结果：经过倾向性评分匹配后，4,053名SGA患者和1,351名L-甲基叶酸甲酯患者在指数日期的12个月内发现SSRI/SNRI指数增加。对照组在年龄、性别、合并症以及SSRI/SNRI的类型和剂量方面匹配良好。在两组中增加的最常见的抗抑郁药物是艾司匹兰、度洛西汀和文拉法辛。从指数到增大的平均时间(标准差[SD])为73.596.7d和L-叶酸甲酯105.9[108.7]d(P 小于 0.001)。用于增强的最常见的SGA是奎硫平、阿立哌唑、
和利培酮。L-叶酸甲酯初始剂量为7.50 mg/d，
急性时相法达标率为68.7%，L-叶酸甲酯为78.7%(P< < 0.001)。增强后50.3%的SGA队列和62.1%的L-甲基叶酸甲酯队列(P 小于 0.001)符合mHEDIS持续时相测量。SGA组的医疗利用(住院、急诊科和门诊)显著高于SGA组，而L-叶酸甲酯组的总处方利用率显著高于SGA组。与抑郁症相关的6个月的平均总成本： = 组为8,499美元[13,585美元]，L-叶酸甲酯组为7,371美元[12,404美元](P 0.005)；与抑郁症相关的6个月成本分别为2,688美元[4,201美元]和1,613美元[2,315美元](P 0.001)。结论：加强SSRI/SNRI治疗的患者获得了69%-79%和50%-62%的MHEDIS AMM急性期和持续性依从性评分。这些修改后的分数超过了2012年商业健康计划未修改的HEDIS AMM措施的国家基准中值。在这项研究中，与SGA强化相比，L-甲基叶酸强化与显著更高的依从性措施相关。此外，与SGA强化组相比，L-甲基叶酸强化组的卫生保健利用率和总卫生保健费用以及与抑郁相关的费用显著降低。
BACKGROUND: Antidepressant monotherapy is effective in achieving treatment remission in only approximately one third of patients with depression, and even switching to a second antidepressant brings the cumulative remission rate to only 50%-55%. This has led to an interest in augmentation therapy for the management of treatment-resistant depression. OBJECTIVES: To assess (a) selective serotonin reuptake inhibitor/selective norepinephrine reuptake inhibitor (SSRI/SNRI) adherence when augmented with second-generation atypical antipsychotics (SGAs) or L-methylfolate using a modified application of the Healthcare Effectiveness Data and Information Set (HEDIS) acute medication management (AMM) measures at the time of augmentation, and (b) the depression-specific and total health care cost, comparing the 2 forms of augmentation therapy in the treatment of depressive disorder. METHODS: Patients with a diagnosis of depression and a pharmacy claim for an SSRI/SNRI between January 1, 2006, and December 31, 2009 (index date), and receiving concomitant augmentation therapy with either an SGA or L-methylfolate (augmentation date), were identified in the MarketScan database and followed for 231 days (follow-up). Patients were excluded for having any pharmacy claim for an antidepressant or SGA 90 days pre-index; having an L-methylfolate claim 6 months pre-index; age less than 18 years on the index date; or a diagnosis of pregnancy, dementia, psychotic-related mental disorders, Alzheimer’s disease, or Parkinson’s disease in the 12-month pre-index period. Propensity score matching (3:1 ratio, atypical antipsychotic to L-methylfolate) was used to select the final study cohorts, using covariates of age, gender, comorbidities, index SSRI/SNRI, and index SSRI/SNRI dose. Adherence to antidepressant therapy was measured from the augmentation date and included a modified application of the HEDIS (mHEDIS) AMM acute and chronic phase measures as well as the 6-month medication possession ratio. Health care utilization and cost were measured for the 6-month postaugmentation period and included both total as well as depression-related utilization/cost. Comparisons between the closely matched SGA and L-methylfolate-augmented cohorts were made using chi-square tests for binary measures and t-tests for continuous measures. RESULTS: Following propensity score matching, 4,053 SGA and 1,351 L-methylfolate patients were found to have augmentation of the index SSRI/SNRI within 12 months of the index date. The comparison groups were well matched on age, gender, comorbidities, and the type and dose of the SSRI/SNRI being augmented. The most common antidepressants augmented in both groups were escitalopram, duloxetine, and venlafaxine. Mean (standard deviation [SD]) time from index to augmentation was 73.5 [96.7] days for SGA and 105.9 [108.7] days for L-methylfolate (P less than 0.001). The most common SGAs utilized for augmentation were quetiapine, aripiprazole,
and risperidone. L-methylfolate was primarily dosed at 7.5 mg/day.
The mHEDIS AMM acute phase measure was met by 68.7% of the SGA cohort and 78.7% of the L-methylfolate cohort (P less than 0.001). The mHEDIS continuation phase measure was met by 50.3% of the SGA cohort and 62.1% of the L-methylfolate cohort (P less than 0.001) following augmentation. Medical utilization (inpatient, emergency department, and outpatient) was significantly higher for the SGA group, while total prescription utilization was significantly higher in the L-methylfolate group. Mean [SD] total 6-month postaugmentation costs for the SGA group was $8,499 [$13,585] and $7,371 [$12,404] for the L-methylfolate group (P = 0.005), and 6-month depression-related costs were $2,688 [$4,201] for the SGA group and $1,613 [$2,315] for the L-methylfolate group (P less than 0.001). CONCLUSIONS: Patients who augmented SSRI/SNRI therapy with SGA or L-methylfolate achieved mHEDIS AMM acute phase and continuation phase adherence scores of 69%-79% and 50%-62%, respectively. These modified scores exceeded the 2012 national median benchmarks for unmodified HEDIS AMM measures for commercial health plans. In this study, augmentation with L-methylfolate was associated with significantly higher adherence measures compared with augmentation with SGA. In addition, health care utilization and total health care costs, as well as depression-related costs, were significantly lower in the L-methylfolate augmentation group compared with augmentation with SGA.
DOI：
10.4088/jcp.7085tx2cj
发表时间：
2011-01
期刊：
The Journal of clinical psychiatry
影响因子：
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作者：
Alexopoulos GS
通讯作者：
Alexopoulos GS
DOI：
10.4088/jcp.v65n0810
发表时间：
2004-08
期刊：
The Journal of clinical psychiatry
影响因子：
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作者：
G. Papakostas;T. Petersen;D. Mischoulon;J. Ryan;A. Nierenberg;T. Bottiglieri;J. Rosenbaum;J. Alpert-J.-Al
通讯作者：
G. Papakostas;T. Petersen;D. Mischoulon;J. Ryan;A. Nierenberg;T. Bottiglieri;J. Rosenbaum;J. Alpert-J.-Al
影响因子：
120.7
作者：
Kessler, RC;Berglund, P;Wang, PS
通讯作者：
Wang, PS