Patient-assigned health state utilities for depression-related outcomes: differences by depression severity and antidepressant medications

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Abstract

Background: Major depressive disorder is a prevalent psychiatric disorder in primary care associated with impaired patient functioning and well-being. We compared patient utilities for hypothetical depression-related and current health states and to examine differences in utilities by patient demographic and clinical characteristics. Methods: Seventy patients with DSM-III-R major depressive disorder or dysthymia who completed at least 8 weeks of antidepressant treatment were recruited from primary care practices. Patients assessments included the Hamilton Depression Rating Scale (HDRS), SF-36 Health Survey, and standard gamble interviews to obtain utilities for 11 hypothetical depression-related states, varying depression severity and antidepressant treatment, and the patient's current health state. Results: The mean utility for severe depression was 0.30 and 25% of patients rated this state as worse than or equivalent to death. Utilities varied from 0.55 to 0.63 for moderate depression, 0.64 to 0.73 for mild depression, and 0.72 to 0.83 for antidepressant maintenance therapy. Statistically significant differences were observed in mean utilities by level of disease severity and by tricyclic antidepressants compared with the newer antidepressants (i.e., fluoxetine, nefazodone). There were no significant differences in utilities for hypothetical states by demographic variables. Mean patient-assigned utilities for current health varied by depression severity and presence of medication side effects. Conclusions: Health state utility scores can be provided by patients with depression and the utility scores provided by patients for hypothetical states demonstrate differences by disease severity and antidepressant treatment. Limitations: The sample size was small which may limit generalizability and statistical power for detecting important differences. The study findings are limited to patients who have successfully completed 8 weeks of antidepressant treatment. Clinical Relevance: Understanding patient preferences for depression outcomes is important for economic evaluations of new antidepressants and for understanding patient behavior and adherence to antidepressant treatment regimens.

Introduction

Depressive disorder is common in primary care patients (Williams et al., 1995) with a 12-month prevalence of 5.0–12.9% in women and 4.0–7.7% in men in the United States population (Weissman, 1991, Kessler et al., 1994). Depression is associated with decreased functioning and well-being (Wells et al., 1989, Hays et al., 1995), increased disability days (Broadhead et al., 1990, Ormel et al., 1994), and increased use of health services and costs (Simon et al., 1995). Antidepressant treatment is effective in reducing depression severity (Potter et al., 1991) and in increasing patient functioning and well-being (Heiligenstein et al., 1995, Simon et al., 1996). Compared with tricyclic antidepressants (TCAs), the selective serotonin reuptake inhibitors (SSRIs) and other newer antidepressants (e.g., nefazodone, venlafaxine) have comparable clinical efficacy (Stark and Hardison, 1985, Potter et al., 1991, Song et al., 1993, Workman and Short, 1993, Rickels et al., 1994, Mendels et al., 1995) and less side effects (Stark and Hardison, 1985, Preskorn, 1995). Despite comparable clinical efficacy, a meta-analysis of discontinuation rates found lower treatment discontinuation rates for SSRIs compared with TCAs (Montgomery et al., 1994). More recently, a randomized effectiveness study (Simon et al., 1996) demonstrated that fluoxetine has significantly lower treatment discontinuation rates and less frequent treatment switches compared with TCAs. Given the comparable depression and health status outcomes of patients treated with TCAs or fluoxetine, Simon et al. (1996)suggested that patient and physician preferences are most important for treatment decisions.

Studies of physical illnesses have suggested that patient values for their self health state impact on decisions about treatment and the outcomes of treatment (Barry et al., 1988Kiebert, 1995Nease et al., 1995Bartman et al., 1997). Patrick et al. (1995)in a study of patients with anxiety disorder found that patient preferences for anxiety-related states were associated with clinical severity and the likelihood of medication treatment. Patient preferences for treatment outcomes and their valuation of the trade-off between reduction in psychiatric symptoms and treatment-related adverse effects may be related to treatment adherence or discontinuation.

Health state utility measurement reflects the preference or desirability for one or more health states. Health state utilities represent a patient's preference for a health outcome when risk and uncertainty is a part of the measurement approach and the standard gamble is the classical technique for utility measurement (Torrance, 1987, Torrance and Feeny, 1989, Bennett and Torrance, 1996). Health state utilities range from 0 (anchored as death) to 1.0 (anchored as complete health). Other techniques can be used to measure health preferences, such as the rating scale or time trade-off, however, these methods assign values and not utilities since uncertainty and risk are not incorporated into the measurement task (Bennett and Torrance, 1996). Health-state utility assessment has been infrequently applied in psychiatric settings (Revicki et al., 1996, Pyne et al., 1997a, Pyne et al., 1997b). Preferences for depression outcomes have implications for individual patient and physician decision-making on selection of antidepressant treatment and for the economic evaluation of the newer antidepressant treatments.

Studies have estimated the utilities and preferences for various health states associated with physical diseases (Barry et al., 1988, Feeny and Torrance, 1989, Torrance and Feeny, 1989, Revicki, 1992, Kiebert, 1995, Nease et al., 1995, Bennett and Torrance, 1996). There is little research on health utilities for psychiatric disorders (Patrick et al., 1995Bennett et al., 1995Revicki et al., 1996Pyne et al., 1997aPyne et al., 1997b), and there are no published studies on standard gamble utilities for depression-related health states provided by patients with depressive disorder. Sackett and Torrance (1978), in a study of the general population in Hamilton, Ontario, found a time trade-off utility of 0.44 for 3 months with depression. However, Bennett et al. (1995)recently reported on the development of a multi-attribute scale designed to measure utilities in patients with depression. More recently, Pyne et al., 1997a, Pyne et al., 1997bused the Quality of Well-Being (QWB) scale to measure preferences in patients with major depression disorder. They found that patients with greater depression severity, measured using the Hamilton Depression Rating Scale, reported lower QWB preference scores. Depression-related utilities are needed to understand patient preferences for depression outcomes and antidepressant side effects, and for economic evaluations of antidepressant treatments (Revicki et al., 1997). The US Public Health Service panel on cost-effectiveness studies recommend that quality-adjusted life years (QALYs) be used as outcomes for cost-effectiveness analyses (Gold et al., 1996). Health state utilities are needed to calculate QALYs, a measure of effectiveness where utility scores are used to adjust duration of time for the effect of disease progression and treatment on health-related quality of life.

The primary objectives of this study are to measure standard gamble utilities for depression-related hypothetical and current health states in patients with major depression disorder and to examine differences in utilities by patient demographic and clinical characteristics.

Section snippets

Patient sample

Seventy patients with major depression disorder were recruited from two outpatient primary care practices to provide estimates of utilities for different hypothetical health outcomes that might be experienced by patients with depression. The patients were identified from a university family practice clinic in Toronto, Ontario (n=40) and a community-based primary care practice in San Diego, California (n=30). Patients were male or female outpatients aged 18–65 years, with a DSM-III-R diagnosis

Results

Of the 70 patients recruited for the study, three patients had incomplete baseline demographic data, 12 patients had missing or incomplete health utility data, nine patients had missing or incomplete health status data and one patient had missing or incomplete clinical data. Mean age was 42 years (SD=11); 23% were male and 48% were married. Eighty-three percent of the patients had greater than high school education and 8% were employed full-time. Thirty-one percent of the Toronto patients were

Discussion

This study evaluated the feasibility and importance of assessing hypothetical and current health state utilities in patients with major depressive disorder. To our knowledge, this is the first study to report standard gamble-derived utilities in patients with depression. We demonstrated that it was feasible to elicit utilities using the standard gamble technique from patients recently recovered from a depression episode. Few patients (3%) could not complete the standard gamble interview and 25%

Acknowledgements

This project was supported by Bristol-Myers Squibb, Princeton, NJ, USA.

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