Adherence and Persistence Across Antidepressant Therapeutic Classes: A Retrospective Claims Analysis Among Insured US Patients with Major Depressive Disorder (MDD)

Abstract

BackgroundAdherence and persistence to therapy, or how well a patient follows provider directions on frequency and time to discontinuation of prescribed medications, is associated with positive health outcomes, including decreased healthcare costs and patient mortality. A clear literature gap exists assessing adherence and persistence to antidepressants (ADs) in the major depressive disorder (MDD) population at clinically relevant time points and at the therapeutic class level.ObjectiveThis study assessed adherence and persistence to specific ADs, therapeutic classes, and AD therapy overall at multiple time points among US individuals from commercial, Medicare supplemental, and Medicaid insurance plans.MethodsPatients with MDD without AD or MDD claims in the prior 6 months who initiated therapy in 2003–2014 with a selective serotonin reuptake inhibitor (SSRI), serotonin and norepinephrine reuptake inhibitor (SNRI), tricyclic AD (TCA), monoamine oxidase inhibitor (MAOI), or other AD were identified using MarketScan® databases. These databases contain information on diagnoses, billing codes, and dates of service. Adherence (proportion of days covered) and persistence (days until a 30-day gap in therapy) were calculated to AD medication, AD therapeutic class, and AD therapy overall over the first 3, 6, 9, and 12 months from the index prescription date. Multivariable logistic regression estimated the adjusted odds ratios (ORs) of adherence to initial AD medication comparing AD therapeutic classes.ResultsFor 527,907 patients, adherence to initial AD medication decreased over 3, 6, 9, and 12 months (41, 31, 24, and 21%, respectively). Similar patterns were observed for adherence to initial AD therapeutic class, AD therapy overall, and all three persistence calculations. The odds of adherence to SNRIs versus SSRIs were 20–27% greater at 3, 6, 9, and 12 months (ORs 1.20, 1.23, 1.25, 1.27, respectively; p-values all <0.0001). Similar or significantly lower odds of adherence were demonstrated for other classes versus SSRIs at 3, 6, 9, and 12 months [ORs for other ADs 0.80, 0.77, 0.74, 0.72, respectively (p-values all <0.0001); ORs for TCAs 0.46, 0.45, 0.47, 0.49, respectively (p-values all <0.0001); ORs for MAOIs 1.13, 1.0, 0.77, 0.69, respectively (p-values all >0.05)].ConclusionWe found low adherence and persistence to ADs in the MDD population. Within the limitations of the insurance claims data we analysed, our results suggest that adherence may differ based on therapeutic class, as patients initiating SNRI therapy appeared to have a higher likelihood of adherence versus SSRIs over the year assessed, while the odds of adherence appeared similar or lower for other classes versus SSRIs. Further prospective research is needed to confirm these findings and determine additional drivers of these apparent differences by AD therapeutic class.Electronic supplementary materialThe online version of this article (doi:10.1007/s40263-017-0417-0) contains supplementary material, which is available to authorized users.

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“…SNRIs was proved to have a higher response rate and less remission, especially for treating depression‐associated neuropathic pain and other pain, as we could see in our results that neurological symptoms and headache were both risk factors. These two results were consistent with a previous study that adherence of SNRIs was better than SSRIs but TCAs was worse . Surprisingly, “not treated by another class of medicine except for anti‐depressants in the current episode” was a risk factor for quitting medication.…”

“…28 While "SNRI-treated first episode" was a protecting factor. SNRIs was proved to have a higher response rate and less remission, 29 especially for treating depression-associated neuropathic pain and other pain, 30 as we could see in our results that neurological symptoms and headache were both risk factors. These two results were consistent with a previous study that adherence of SNRIs was better than SSRIs but TCAs was worse.…”

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“…With respect to the uncertainty around the mean estimate of the state‐transition probabilities and risk ratio, the beta and lognormal distribution were adopted, as shown in Table …”

“…Therefore, the health utility of the dropout state was calculated by the following formula: where U drop , U dep , U rem , and P rem represent the health utility of the dropout state, depression state, and remitted state, and the probability of patients being remitted without treatment among all dropout patients, respectively. Here, the probability was estimated as 0.31 on the basis of the results from Keyloun et al and Sawada et al Hence, the means of the health utilities for dropouts were: 0.45 for severe depression and 0.66 for moderate depression. With respect to health‐related utility, the beta distribution was supposed for the distribution of health‐related utility scores.…”

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