PubMed1998
BACKGROUND: Evaluating treatments for depression is of great importance given that estimates of lifetime prevalence range up to 20 per cent. The class of antidepressants known as Selective Serotonin Reuptake Inhibitors (SSRIs) has been a major innovation in this area, but has also raised questions about their cost-effectiveness as a first-line treatment, due to their high price compared to other drugs. AIMS OF THE STUDY: The study aimed to contribute to this debate, from within the context of European health care systems. These systems share a common set of pressures to contain costs, many of which, in Europe, are funded from public finances, unlike the US system, with its greater private sector involvement. METHODS: A range of published papers were reviewed. They all covered the general area of costs and SSRIs and were evaluated in a European context. RESULTS: Some studies have considered the possible use of SSRIs purely as a matter of accounting costs. Not surprisingly, they have argued against switching, on the grounds of high acquisition costs. However, studies based alongside clinical trials have incorporated efficacy into the analysis. They have produced cost-effectiveness or cost utility based arguments in favour of the SSRIs or other innovative, high-price antidepressants. Another approach has used retrospective analysis of real patients'experience of treatment. This has shown that, if the full costs of treatment are considered, there is an argument for switching from Tricyclic Antidepressants (TCAs) to first-line use of SSRIs. Most economic evaluations have used decision analysis techniques and thus are subject to all the qualifications that apply to such modelling exercises. With only one exception, all the studies in this category were in favour of switching to newer antidepressants. While efficacy was generally accepted as roughly equal, the newer products were seen as less toxic and better tolerated. The consequence was savings in health care costs that outweighed the increase in drug acquisition costs. DISCUSSION: The economic evaluation papers in this review have almost all challenged the view that health care providers should regard SSRIs as 'too expensive' for widespread use. Instead, if one integrates clinical outcomes with a full range of health care costs the high-price products may be more cost-effective. Certainly that is the message from this review, although the observations must be qualified, as most of the studies considered were UK based. CONCLUSIONS: In all health care systems there are now incentives to control costs, which may act as a disincentive to the use of SSRIs, but if those responsible for drug budgets also have financial responsibilities outside the drug budget they will also have an incentive to control those areas. In this case, there is a body of evidence to suggest they would gain by switching to SSRIs. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Decisions on favoured classes of antidepressant for first-line treatment should not be made purely on the basis of drug costs. The implications for all aspects of health spending should be included in the deliberations. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The impact of spending across all budgets should be considered when drawing up policy on the use of new health care technologies, such as the SSRIs. IMPLICATIONS FOR FURTHER RESEARCH: Most studies in this area have used modelling techniques, which are subject to a number of limitations. They have also used results taken from the artificial environment of clinical trials. Future research should aim to generate economic evaluations based on effectiveness amongst real patients in clinical practice.