BackgroundFrench clinical recommendations suggest prescribing long-acting injectable (LAI) antipsychotics to patients with a maintenance treatment indication in schizophrenia. Despite this, and due to their relatively high acquisition and administration costs, LAIs are still underused in clinical practice in France, thus highlighting the need for pharmacoeconomic evaluations.ObjectiveOur objective was to estimate the cost effectiveness of paliperidone LAI (or paliperidone palmitate), a once-monthly second-generation LAI antipsychotic, compared with the most common antipsychotic medications for the maintenance treatment of schizophrenia in France.MethodsA Markov model was developed to simulate the progression of a cohort of schizophrenic patients through four health states (stable treated, stable non-treated, relapse and death) and to consider up to three lines of treatment to account for changes in treatment management. Paliperidone LAI was compared with risperidone LAI, aripiprazole LAI, olanzapine LAI, haloperidol LAI (or haloperidol decanoate) and oral olanzapine. Costs, quality-adjusted life-years (QALYs) and number of relapses were assessed over 5 years based on 3-month cycles with a discount rate of 4 % and from a French health insurance perspective. Patients were considered to be stabilised after a schizophrenic episode and would enter the model at an initiation phase, followed by a prevention of relapse phase if successful. Data (e.g. relapse or discontinuation rates) for the initiation phase came from randomised clinical trials, whereas relapse rates in the prevention phase were derived from hospitalisation risks based on real-life French data to capture adherence effects. Safety and utility data were derived from international publications. Additionally, costs were retrieved from French health insurance databases and publications. Finally, expert opinion was used for validation purposes or in case of gaps in data. The robustness of results was assessed through deterministic and probabilistic sensitivity analyses.ResultsAll LAI antipsychotics were found to have similar costs over 5 years: approximatively €55,000, except for paliperidone LAI which had a discounted cost of €50,880. Oral olanzapine was less costly than LAIs (i.e. €50,379 after 5 years) but was associated with fewer QALYs gained and relapses avoided. Paliperidone LAI dominated aripiprazole LAI, olanzapine LAI and haloperidol LAI in terms of costs per QALY, and it was associated with slightly fewer QALYs when compared with risperidone LAI (i.e. 3.763 vs 3.764). This resulted in a high incremental cost-effectiveness ratio (ICER) (i.e. €4,770,018 per QALY gained) for risperidone LAI compared with paliperidone LAI. Paliperidone LAI was more costly than olanzapine oral but associated with more QALYs (i.e. ICER of €2411 per QALY gained for paliperidone LAI compared with oral olanzapine). Paliperidone LAI had a probability of being the optimal strategy in more than 50 % of cases for a willingness-to-pay threshold of €8000 per QALY gained.Conclusion...

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A459peridone. Methods: Cost-utility analysis was performed using a Markov model. The primary outcome was ICER/QALY. Oral risperidone, oral paliperidone and long-acting risperidone were selected as comparators. The basic components of the model include probabilities of relapse, individual hazard ratios for non-compliance by medication type and switch of treatment probabilities. Specific utilities for each health state were considered. Among relevant costs, reflecting payer's perspective, drug acquisition costs, monitoring costs, costs of relapses, follow-up care and adverse events were considered. Results: Long-acting paliperidone reached ICER of EUR 16,233/QALY compared to oral risperidone, EUR 15,058/QALY to oral paliperidone and EUR 335/QALY to long-acting risperidone. The robustness of the model was supported by one-way deterministic analysis and probabilistic sensitivity analysis, which gave stable results. Long-acting paliperidone was cost effective in 97% of the simulations compared to oral risperidone. Long-acting paliperidone treatment gained incremental 0.903 QALYs on average compared to oral risperidone. ConClusions: The treatment of schizophrenia using long-acting paliperidone is associated with increased QALYs. It reduces incidence of adverse events, results in better prevention of relapses and can be considered a cost-effective treatment in the Czech Republic. PMH34Cost-Utility of Vortioxetine in tHe treatMent of Major DePressiVe DisorDer: CoMParison witH agoMelatine, BUProPion, sertraline anD Venlafaxine in tHe finnisH setting objeCtives: Switching to vortioxetine (a new antidepressant) after inadequate response to selective serotonin re-uptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) resulted in a significant and clinically relevant improvement versus agomelatine (REVIVE head-to-head clinical study) and also better efficacy over sertraline, venlafaxine and bupropion (indirect comparison). The aim of this study is to assess the Finnish cost-utility of vortioxetine versus these antidepressants in patients who switch due to inadequate response to previous treatments. Methods: A one year cost-utility analysis was performed using a decision tree model for the second line and a Markov model for subsequent lines of MDD treatment. Undiscounted payer and societal perspectives were considered. Three health-states (depression, remission, recovery) and two treatment phases (2-month acute, 6-month maintenance) were defined. The relative efficacy of antidepressants was derived from the REVIVE trial and indirect comparisons at 2 months. Efficacy in subsequent treatment steps was derived from the STAR * D study. Adverse events and their consequences were included and derived from REVIVE, indirect comparisons, literature and expert opinion. Utilities were derived from REVIVE and the literature using Finnish preference weights. Finnish costs in 2013/2014 value were considered. Sensitivity analyses were conducted to assess the robustness of the findings. Results: Vortioxetine was dominant fro...

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Contexte La stimulation magnétique transcrânienne (rTMS) est un traitement efficace de la dépression résistante. Sa place relative par rapport aux ECT dans la stratégie thérapeutique est questionnée ainsi que leur possible complémentarité. Matériels et méthodes Nous avons procédé à une synthèse de la littérature sur Pubmed fin juin 2014 avec la combinaison des mots clés suivants : ECT, mECT, rTMS, versus, adjuvant, add-on, comparative, efficacy, maintenance treatment, relapse, longitudinal follow-up, depression. Résultats et discussion La rTMS peut être aussi efficace que l'ECT à coût équivalent sous certaines conditions (durée > 4 semaines, plus de 1200 pulses par séance, moins d'échecs médicamen-teux antérieurs, et surtout absence de symptômes psychotiques). Les mécanismes d'action sont en partie communs : neurogenèse, sécrétion de facteurs neurotrophiques, transmission monoaminergique, gabaergique et glutamatergique, régulation de l'axe hypothalamo-hypophysaire et régulation de l'activité cérébrale frontal et limbique. L'action rapide de la rTMS sur le risque suicidaire reste à démontrer mais elle présente probablement un meilleur profil de tolérance cognitive en cure initiale, voire un effet procognitif. Dans les deux cas le taux de rechute est estimé entre 40 et 50 % à 3 mois en l'absence de prophylaxie adéquate. Le traitement d'entretien par rTMS consiste le plus souvent en 2 séances sur une journée de faç on hebdomadaire sans consensus actuellement sur cette question. Bien que les ECT de maintenance soient bien tolé-rées, certains patients fragiles du fait de co-morbidités, ou réticents à certains traitements psychotropes, ou craignant les anesthésies, pourraient bénéficier de rTMS en relais des ECT. Plusieurs séries de cas plaident en ce sens. Conclusion Des essais prospectifs longitudinaux avec présence de groupes contrôles sont souhaitables, contrôlant sur la durée les traitements et les aspects cognitifs de faç on objective et comparative. La rythmicité, les sous-groupes cliniques éligibles, et les traitements associés restent à préciser. Mots clésECT ; rTMS ; Dépression résistante ; Stratégie thérapeutique ; Complémentarité Déclaration d'intérêts Les auteurs déclarent ne pas avoir de conflits d'intérêts en relation avec cet article. Pour en savoir plus Berlim MT, Van den Eynde F, Daskalakis ZJ. Efficacy and acceptability of high frequency repetitive transcranial magnetic stimulation (rTMS) versus electroconvulsive therapy (ECT) for major depression: a systematic review and meta-analysis of randomized trials. Depress Anxiety 2013;30 (7):614-23. Xie J, Chen J, Wei Q. Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for major depression: a meta-analysis of stimulus parameter effects. Neurol Res 2013;35(10):1084-91. Noda Y, Daskalakis ZJ, Ramos C, Blumberger DM. Repetitive transcranial magnetic stimulation to maintain treatment response to electroconvulsive therapy in depression: a case series. Front Psychiatry 2013;4:73. http://dx. ObjectifÉvaluer l'efficience du palmitate de...