Introduction
Depression is the leading cause of disability worldwide, the United Nations (UN) health agency reported, estimating that it affects more than 300 million people worldwide – the majority of them women, young people and the elderly. An estimated 4.4 percent of the global population has depression, according to a report released by the UN World Health Organization (WHO), which shows an 18 percent increase in the number of people living with depression between 2005 and 2015.1, 2, 3
Depression is a major mental-health cause of disease burden. Its consequences further lead to significant burden in public health, including a higher risk of dementia, premature mortality arising from physical disorders, and maternal depression impacts on child growth and development.4 Approximately 76% to 85% of depressed people in low- and middle-income countries do not receive treatment;5 barriers to treatment include: inaccurate assessment, lack of trained health-care providers, social stigma and lack of resources.6
The stigma comes from misguided societal views that people with mental illness are different from everyone else, and they can choose to get better only if they wanted to.7 Due to this more than half of the people with depression do not receive help with their disorders. The stigma leads to a strong preference for privacy.
The Greco-Roman world used the tradition of the four humors to attempt to systematize sadness as "melancholia". This concept remained an important part of European and Islamic medicine until falling out of scientific favor in the 19th century.8 Emil Kraepelin gave a noted scientific account of depression (German: das manisch-depressive Irresein) in his 1896 psychology encyclopedia "Psychiatrie".9
According to a survey, the Indian pharmaceutical market is 3rd in volume and 13th in value in the world. Branded generic drugs market is 70-80% in India. Even though production is more in India, still all people do not get.
Medicines because of high cost.7 In Indian pharmaceutical market there is a huge number of formulations of antidepressant drugs, and the same formulations are sold under different brands.8 Prices of drugs are kept at high by manufacturing company and it makes the drug less affordable for poor people.9 Pharmaco-economics plays an important role in practice of medicine in developing countries. Majority of healthcare expenditures are paid by the population (67%-70%), whereas the government accounts for only 30%-33%. The compliance to treatment by the patient is significantly dependent on the cost of the prescribed medicines.7, 8
Antidepressant drugs are available in many different brands and costs of all brands are different. Patients of depression have to take the antidepressant drug for a longer duration. If the cost of a drug is high, the patient has to pay more money for complete treatment. It can result in noncompliance and treatment failure.9 Lack of knowledge about the cost of various brands of different antidepressant drugs can lead to difficulties in prescribing the same effective treatment regime at low cost for the patient. So this study was designed to evaluate the cost of antidepressant drugs of different generic classes and different brand names and to analyze price variation among various antidepressant drugs available in India.
The present study was performed to evaluate the cost effectiveness of various drugs prescribed for depression at a rural teaching hospital.
Materials and Methods
A cross sectional study was performed by collecting the data from the outdoor patient department of the Psychiatric department. Patients of all ages and both sexes were included in the study. Indoor patients, referred patients and as well as patients suffering from concomitant disease like hypertension, diabetes mellitus, epilepsy were excluded from the study. Cost of the prescribed antidepressants both single and fixed dose combinations of different companies were obtained from Current Index of Medical specialties (CIMS),
Completeness of data
Number of antidepressants prescribed
Most commonly prescribed antidepressant
Percentage of polytherapy
Average daily dose
The pharmacoeconomic evaluation comprised of:
The data was analyzed using Microsoft excel.
Results
The study was carried for a period of two months.Total 250 cases was reviewed.
Depression (76%) was the most prevalent psychiatric ailment followed by anxiety (13%) and schizophrenia (11%).Figure 1
Depression was most prevalent in the age group of 21-40 years (38.4%). Females were more sufferers of depression (71.54%).
Table 1
The drugs prescribed were classified as follows
|
Class |
Drug |
|
Selective Serotonin reuptake inhibitor |
Citalopram Escitalopram Fluoxetine Paroxetine Sertraline |
|
Tricyclic Antidepressants |
Amitriptyline Nortriptyline Clomipramine Imipramine |
Fixed dose combination most commonly prescribed was of Escitalopram and Clonazepam 45%.Figure 3
Table 2
Analysis of prescription of antidepressants
|
Total number of Prescriptions analyzed |
250 |
|
Incomplete data |
17 |
|
No antidepressant prescribed |
03 |
|
Prescriptions having antidepressants |
233 |
|
Prescriptions having two or more drugs |
09 |
Table 3
Cost of drugs prescribed in the study
Out of the 250 patients antidepressant monotherapy was found in 76% patients. The cost of therapy was taken out by prescribing the drugs for a period of 30days on an average.The most expensive therapy was Paroxetine(Rs 221), the cheapest was Imipramine(Rs 21).Table 2, Table 3.
Discussion
In our study it was observed that Depression was the most diagnosed psychiatric condition at the opd(76%).Majority of the patients reported were females(71.54%) in the age group of 21-40years(38.54%) which is in accordance with the study of Bohra, Neena et al. “Depression in women in Indian context.” Indian journal of psychiatry vol. 57, Suppl 2 (2015): S239-45. doi:10.4103/0019-5545.161485
Rational use of medicines is that the patient receives medication appropriate to the clinical need, at the proper dose, for the proper duration and at the lowest cost. So for rational prescribing, prescriber should also consider the cost while writing prescription along with other criteria of rational use of the drug.10
Cost of the drug is an important factor and prescribers are not aware of all different brands of drugs available and their prices. So studies about comparing the cost of a different class of drugs and their different brands can provide some knowledge to prescriber about the cost of different drugs in the specific disease condition.93.2% of prescriptions had antidepressants included in them.3.6% of prescriptions were those having two or more drugs.
This survey revealed fluoxetine was the most popular antidepressant as analogous to the study Rossi, Andrea et al. “Fluoxetine: a review on evidence based medicine.” Annals of general hospital psychiatry vol. 3,1 2. 12 Feb. 2004, doi:10.1186/1475-2832-3-2. In the study by Dunlop, Boadie W, and Paula G Davis. “Combination treatment with benzodiazepines and SSRIs for comorbid anxiety and depression: a review.” They reported that the combination of benzodiazepines with SSRIs was beneficial for the outcomes which was also confirmed in our study.
As mentioned in the study by Melton ST, Kirkwood CK, Farrar TW, Brink DD, Carroll NV. Economic evaluation of paroxetine and imipramine in depressed outpatients. Psychopharmacol Bull. 1997;33(1):93-100. PMID: 9133757, the cost of Paroxetine therapy was most expensive while that of Imipramine was cheapest,the same results were found in our study.
Conclusion
Economic evaluations of treatments for depression should, where possible and appropriate, take place alongside pragmatic studies of the effectiveness of interventions, have adequate power to demonstrate significant differences in cost and cost-effectiveness, use universal outcomes such as quality-of-life scales alongside the usual condition-specific scales so that different interventions can be compared and take a wide view of costs, given the importance of productivity losses in depression.
