Eficacia y costos asociados a un tratamiento ambulatorio en mujeres con depresión severa y trauma temprano / Efficacy and associated costs of an outpatient intervention in women with severe depression and early trauma

Background: A high proportion of women consulting for depression have a history of childhood abuse and trauma. Aim: To compare the effcacy and costs associated with a treatment that inquires directly into childhood trauma and understands present interpersonal diffculties as a compulsion to repeat the traumatic past, versus the usual treatment, in women with severe depression and childhood trauma. Material and Methods: Eighty seven women with depression and prior history of early trauma that sought help at the Mental Health Unit of the Hospital de Curicó were studied. Forty four were randomly assigned to the experimental treatment, and 43 to the usual management. Patients were evaluated using the Hamilton Depression Scale, the Outcome Questionnaire (OQ 45.2) and an expenditures sheet at baseline, three and six months. An intention to treat analysis and a simple cost-analysis were performed. Results: Hamilton and OQ 45.2 scores improved in both treatment groups, with signifcantly better results achieved in the experimental patients. The direct overall costs of experimental and control treatments were CLP 8,628,587 and 9,688,240, respectively. The main contributors to costs in both arms were medications (26.5 percent), followed by the number of psychiatric consultations (19.2 percent) in the experimental group and by hospitalizations (25.4 percent) in the control group. The costs per patient recovered in experimental and control groups were CLP 616,328 and 1,973,649, respectively. Conclusions: The proposed model resulted more effective for the treatment of this group of women.

Pharmacoeconomics of antidepressants in moderate-to-severe depressive disorder in Colombia / Farmacoeconomía de antidepresivos en trastornos de depresión moderada e intensa en Colombia

OBJECTIVE: To compare three antidepressant drugs from different classes used in treating moderate-to-severe major depressive disorder (MDD) in Colombian adults. METHODS: Based on expert input, a decision-tree model was adapted for Colombia to analyze data over 6 months from the government-payer perspective. The cost-effectiveness of amitriptyline, fluoxetine, and venlafaxine was determined. The clinical outcome was remission of depression (a score <7 on the Hamilton Depression [HAM-D] scale or <12 on the Montgomery-Åsberg Depression Rating Scale [MADRS]) after 8 weeks of treatment. Clinical data were obtained from the literature and costs from standard Colombian price lists. One-way and multivariate sensitivity analyses tested model robustness. RESULTS: Costs per patient (in 2007 US$) for treatment were: venlafaxine, $1 618; fluoxetine, $1 207; and amitriptyline, $1 068. Overall remission rates were 73.1 percent, 64.1 percent, and 71.3 percent, respectively. Amitriptyline dominated fluoxetine (i.e., it had lower costs and higher outcomes). The incremental cost-effectiveness ratio (ICER) of venlafaxine over amitriptyline was US$ 31 595. The acquisition price of venlafaxine was the model's cost driver, comprising 53.4 percent of the total cost/patient treated, compared with 18.5 percent and 24.8 percent for fluoxetine and amitriptyline, respectively. For the others, hospitalization comprised the major cost (72.1 percent and 65.2 percent, respectively). Probabilistic (Monte Carlo) sensitivity analysis confirmed the original findings of the pharmacoeconomic model. CONCLUSIONS: Amitriptyline is cost-effective in comparison to fluoxetine and venlafaxine in Colombia. However, the cost of venlafaxine was estimated for the brand-name product, as generics were not currently available. These cost-effectiveness results can be substantially affected by the presence of generics or drug cost regulations.

OBJETIVO: Comparar tres medicamentos antidepresivos de diferentes clases empleados para tratar trastornos depresivos mayores moderados e intensos en adultos colombianos. MÉTODOS: A partir de los aportes de expertos se adaptó un modelo de árbol de decisión para Colombia a fin de analizar los datos de seis meses desde la perspectiva del gobierno como pagador de los servicios. Se determinó la relación costo-efectividad de la amitriptilina, la fluoxetina y la venlafaxina. El desenlace clínico fue la remisión de la depresión (una puntuación <7 en la escala de depresión de Hamilton o <12 en la escala de valoración de la depresión de Montgomery-Åsberg) después de 8 semanas de tratamiento. Los datos clínicos se obtuvieron de la literatura especializada y los costos, de las listas habituales de precios de Colombia. Se realizaron análisis de sensibilidad simples y multifactoriales para probar la robustez de los modelos. RESULTADOS: Los costos del tratamiento por paciente (en dólares estadounidenses de 2007) fueron: US$ 1 618 para la venlafaxina, US$ 1 207 para la fluoxetina y US$ 1 068 para la amitriptilina. Las tasas de remisión general fueron 73,1 por ciento, 64,1 por ciento y 71,3 por ciento, respectivamente. La amitriptilina tuvo un menor costo y una mayor remisión que la fluoxetina. La razón de rentabilidad incremental de la venlafaxina sobre la amitriptilina fue de US$ 31 595. El inductor de costos (cost driver) del modelo fue el valor de adquisición de la venlafaxina, que representó 53,4 por ciento del total del costo por paciente tratado, en comparación con la fluoxetina (18,5 por ciento) y la amitriptilina (24,8 por ciento). En los otros casos, la hospitalización representó el mayor costo (72,1 por ciento y 65,2 por ciento, respectivamente). El análisis de sensibilidad probabilístico (Monte Carlo) confirmó los resultados preliminares del modelo farmacoeconómico. CONCLUSIONES: En Colombia, la amitriptilina es más efectiva en función del...

Consumo de antidepresivos en Chile entre 1992 y 2004 / Consumption of antidepressants in Chile from 1992 to 2004

Background: Data from the Ministry of Health show that in Chile in 2004, 17 percent of the population had some form of depression and mood disorders are the tenth cause of disability-adjusted Ufe years (DALY) loss. Aim: To determine consumption of antidepressants (ADs) in Chile from 1992 to 2004. Material and methods: National sales data were obtained from the company IMS Health Chile and converted into defined daily doses (DDDs) per 1,000 inhabitants per day Available ADs were classified in four pharmacological groups (i.e., serotonin-norepinephrine reuptake inhibitors, SNRIs; selective-serotonin reuptake inhibitors, SSRIs; tricyclic antidepressants, TCAs; and others). Total economic burden of ADs utilization and cost per DDDs were also calculated. Trends over time were analyzed using Pearson-R2. Results: Total ADs consumption in Chile measured by DDDs per 1,000 inhabitants per day (DHD) increased linearly (y =0.901x+1.9129; R2 =0.9296; p <0.001) from 2.5 in 1992 to 11.7 in 2004 (total growth of 470.2 percent). SSRIs were the drug class with higher consumption, and fluoxetine the most commonly consumed antidepressant. SSRIs were the drugs that dominated the market representing 79 percent of the total drug consumption throughout the years. Total economic burden of ADs in Chile (total cost of DDDs consumed) increased from US$65.4 million in 2001 to US$74.6 million in 2004 (14 percent increase). Average cost per DDD of all AD increased linearly, however not significantly from US$ 0.94 in 2001 to US$ 1.04 in 2004 (y =0.0362x+0.8784; R2 =0.7382; p =0,262). Conclusions: DDDs per 1,000 inhabitants per day increased linearly over 470 percent from 1992-2004. SSRIs were the most commonly consumed drugs in Chile. Future research should evaluate the cost-effectiveness of antidepressants in Chile, comparing the results with drug utilization, and determining if unnecessary expenditures have been paid out.

Depressäo unipolar: uma revisäo / Unipolar depression: a review

A depressäo é uma doença grave e comum, associada com prejuízo do funcionamento social e ocupacional, e com alto custo econômico. Pesquisas e observaçöes clínicas têm demonstrado que pacientes com depressäo têm uma significativa probabilidade de apresentar recaída, recorrência, cronicidade e sintomas subsindrômicos residuais entre os episódios da doença. Apesar de sua gravidade, observou-se que muitos pacientes näo säo adequadamente diagnosticados e tratados na populaçäo geral. Até o momento, pouco se sabe sobre a patogênesee a fisiopatologia da depressäo. Assim como, nenhum marcador biológico apresenta sensibilidade, especificidade e valor preditivo para auxiliar o diagnóstico dos transtornos depressivos, prever sua evoluçäo, orientar a terapêutica e promover a seleçäo de pacientes. Existem questöes ainda näo resolvidas no tratamento da depressäo unipolar recorrente. A primeira diz respeito à duraçäo do tratamento. Atualmente, há uma tendência em se manter a dose de antidepressor usada na fase aguda. Aproximadamente, 20 a 30 por cento dos pacientes com transtorno depressivo maior näo têm uma resposta satisfatória ao tratamento com antidepressores. Esta "näo resposta" ao tratamento pode resultar de um erro diagnóstico, do tratamento inadequado, da coexistência de outras condiçöes médicas e psiquiátricas e/ou de fatores psicosociais complicadores

Los trastornos depresivos y su impacto socioeconómico / Depressive disorders and their socioeconomic impact

Se lleva a cabo una revisión bibliográfica acerca del impacto socioeconómico de los trastornos depresivos. Santiago de Chile tiene tasas de prevalencia semestrales de trastornos psiquiátricos más altas que otras ciudades del mundo, siendo los trastornos afectivos los más frecuentes. Estudios internacionales indican que las personas que sufren de trastornos depresivos experimentan un cúmulo de limitaciones funcionales, físicas y psicosociales, y altas tasas de días de reposo. Esto tiene un impacto considerable en el bienestar personal, en las relaciones interpersonales y en la productividad laboral debido a la alta prevalencia de estos trastornos. Las estimaciones del Banco Mundial sobre discapacidad y años de vida saludable perdidos por trastornos depresivos figuran entre las más altas, sólo superadas por la carga de morbilidad atribuible a las enfermedades cardiovasculares. En Chile, la Depresión Mayor constituye la segunda causa de pérdida de años de vida ajustado por discapacidad en las mujeres de edad adulta. A pesar que se han producido enormes avances en los últimos años en el tratamiento de las enfermedades mentales y que la depresión tiene una respuesta muy buena a éste, un porcentaje importante de los afectados por ella nunca recibe tratamiento y, por ende, mantiene la sintomatología y la discapacidad,con lo cual se genera un alto costo económico a la sociedad