Tanya Hughes1, Gwen Zeno1, Emily Wiggins2, Xiaoyun Yang2, Joshua N. Liberman2, Charles Ruetsch2
1Orexo US, Inc, 2Health Analytics, LLC
A summary of our poster presented at the AMCP Nexus 2022 conference (October 11-,20222 – October 14, 2022).
Study Background
Major depressive disorder (MDD) is a common, debilitating condition1. Though the APA recommends treating MDD with a combination of psychotherapy and pharmacotherapy2, many who initiate pharmacotherapy do not add psychotherapy. As the direct medical and pharmacy care costs for individuals with MDD are substantial3, there is a need to understand the association between adjunctive psychotherapy and costs of healthcare resource utilization.
Study Objective
To compare healthcare costs between individuals with MDD who initiated pharmacotherapy who did and did not add adjunctive psychotherapy in the subsequent two-year period.
Methodology
Study Design
This was a matched cohort comparison study among individuals with MDD who initiated pharmacotherapy who did and did not add adjunctive psychotherapy in the subsequent two-year period.
Study Periods
- Case finding period: January 1, 2016-February 28, 2019
- Index date was defined as the initiation of an eligible pharmacotherapy.
- Baseline period: 12 months prior to the index date.
- Follow-up period: 24 months following the index date.
Identification and Selection of Study Participants
Eligible participants were identified using a commercially-available open medical and pharmacy insurance claims database, licensed from Clarivate Real-World Data.
To be eligible for inclusion, an individual had to meet each of the following criteria:
- 18-55 years old age at the beginning of baseline.
- Diagnosed with MDD, defined by two or more outpatient claims for services related to MDD separated by at least 30 days or by a single inpatient hospitalization claim with an MDD code in the primary position.
- Pharmacy claim for an eligible antidepressant medication (SSRI, SNRI, bupropion, alpha-2 receptor antagonist, MAOI, serotonin modulators, tricyclic, tetracyclic) on or after the initial MDD diagnosis date.
Individuals were excluded from participation based on the following criteria:
- Diagnosis of MDD with psychotic features, psychosis, bipolar disorder, schizophrenia, or schizoaffective disorder (2+ outpatient claims, separated by 30 days) any time during the study period.
Eligible individuals were stratified into two groups. The Adjunctive Psychotherapy cohort included individuals who added psychotherapy in the follow-up period. The Pharmacotherapy Only cohort did not add psychotherapy in the follow-up period.
Matching
The Adjunctive Psychotherapy and Pharmacotherapy Only cohorts were propensity-score matched (1:1) on the following: gender (m/f), age (+/- 1 year), insurance (commercial, Medicare, Medicaid, other), index antidepressant drug class, index prescriber (PCP, Psychiatrist, Other Specialty, Other), mean Charlson Comorbidity Index score, and all-cause baseline total healthcare costs (+/-5%).
Outcome Measures
Costs ($ per patient per year (PPPY)) for the following: inpatient hospitalizations, emergency department visits, outpatient visits, other medical services, pharmacy, total medical, and total healthcare costs (medical + pharmacy). Cost categories were segmented into psychiatric, non-psychiatric, and all-cause.
Analysis
Bivariate analyses were conducted comparing utilization costs in the follow-up period among a matched sample of cases and controls. Comparison of unadjusted mean costs between the Adjunctive Psychotherapy and Pharmacotherapy Only cohorts in the follow-up period were conducted using t-tests with p<0.05.
Results
The study cohorts were comparable on all characteristics included in the propensity-score matching process.
Throughout the follow-up period, pharmacy costs per patient declined in both cohorts and were consistently lower among the Adjunctive Psychotherapy cohort. All-Cause Total Medical Cost for the Adjunctive Psychotherapy cohort declined more rapidly during the first year of follow-up compared to the Pharmacotherapy Only cohort.
At the end of the first year of follow-up, Adjunctive Psychotherapy had higher total healthcare costs for psychiatric utilization ($5,025 vs $2,402) and lower total healthcare costs for medical services ($10,098 vs $13,540) and all-cause ($15,123 vs $15,942) compared to the Pharmacotherapy Only (all ps<0.05).
At the end of the second year of follow-up, Adjunctive Psychotherapy total healthcare costs were still greater for psychiatric utilization ($2,031 vs $1952), but not significantly so. Total healthcare costs for medical services ($6,153 vs $12,695) and all-cause ($8,184 vs $14,648) (all ps<0.05) decreased dramatically.
Comparing the first year and second year of all-cause utilization for Adjunctive Psychotherapy, there was a reduction of costs for inpatient hospital visits ($2,263 vs $820), ED visits ($772 vs $310), outpatient visits ($5,878 vs $2,175), other medical services ($1,949 vs $848), pharmacy ($4,262 vs $4,032), and total healthcare costs ($15,123 vs $8,184).
Summary
Our results suggest that individuals who add adjunctive psychotherapy to a pharmacotherapy regimen have lower costs for acute care services, higher costs for outpatient care services, and lower all-cause total costs of care compared to individuals who do not add psychotherapy.
Though psychiatric-specific healthcare costs in the Adjunctive Psychotherapy cohort are higher in the first year following treatment initiation, total psychiatric costs are comparable to the Pharmacotherapy Only group in year two.
The association between adjunctive psychotherapy and healthcare costs highlight the importance of initiating psychotherapy alongside pharmacotherapy as part of the treatment of MDD.
Limitations
Clarivate does not include continuous eligibility. The study required the presence of claims for healthcare services or pharmacy during each quarter of the measurement period as a proxy for eligibility.
Initiating psychotherapy was a central grouping factor but is not directly measurable in claims data. The study used a paid claim for a psychotherapy visit as the closest proxy.
Citations
1.NIMH Health Statistics, Major Depression. https://www.nimh.nih.gov/health/statistics/major-depression.shtml (accessed 8/8/2022).
2.APA Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts (2019).
3.Greenberg, P.E., Fournier, AA., Sisitsky, T. et al. The Economic Burden of Adults with Major Depressive Disorder in the United States (2010 and 2018). Pharmacoeconomics 39, 653–665 (2021). https://doi.org/10.1007/s40273-021-01019-4
