The cost of MDD appears well managed, but the burden is greater than ever

MDD = major depressive disorder

Image of bubbles that form a woman’s head

MDD = major depressive disorder

Even before the COVID-19 pandemic, the increased prevalence of major depressive episodes (MDEs) in the United States signaled a rising burden of MDD.^1,2 This burden continues to rise with a 3-fold increase in depression symptoms in 2020.³

It’s time to reevaluate how we manage MDD

Early improvement matters

Early improvement within the first 2 weeks of depressive symptom onset was a discriminative predictor for achieving MDD response and remission in previously completed studies.^4,5*

In a longitudinal study^5†

With early remission

Patients returned to average normal functioning as early as 6 weeks.

Without early remission

Patients took up to 1 year to regain average normal functioning.

Defining Early Improvement⁴

Improvement is commonly defined as a ≥20% change from baseline in depression scale scores. Two weeks is the time point often used in studies assessing the predictive value of early improvement.⁴
Defining Early Response⁵
Early response is defined by a 50% improvement from baseline in Hamilton Depression Rating Scale (HDRS)-17 score by week 6.⁵

Defining Normal Functioning⁵
Functioning was assessed using the Social and Occupational Functioning Assessment Scale. A score above 80 indicates a normal level of functioning.⁵
Defining Early Remission⁵
Early remission is defined by a Hamilton Depression Rating Scale (HDRS)-17 score ≤7 by week 6 without any change in treatment during that period.⁵

*Wagner 2017
Systematic review and meta-analysis assessing the predictive value of earlier improvement on later response and remission at 12 weeks. Included 17 randomized controlled trials in 14,779 adult patients with MDD. Early improvement was defined as a Hamilton Depression Rating Scale (HDRS)/Montgomery-Asberg Depression Rating Scale (MADRS) sum score reduction of greater than or equal to 20%, 25%, or 30% of depression severity from baseline to day 7 or day 14. Response was defined as a 50% reduction in depression severity from treatment initiation to discharge. Remission of the depressive symptomatology was defined as a cut-off score of 7 in the HDRS or 12 in the MADRS at the end of treatment.⁴
^†Cuidad 2012
Prospective longitudinal, multicenter study including 930 adult patients with MDD with an index depressive episode who had begun follow-up for their current episode. Severity assessed using the 17-item Hamilton Depression Rating Scale (HDRS)-17. Functioning assessed using the Social and Occupational Functioning Assessment Scale.⁵

Patients with MDD

For patients with MDD, returning to baseline is a primary goal for treatment⁶

In one study (N=535), patients identified 3 factors as very important to determining remission^6‡:

Return to usual level of functioning
Return to one’s usual normal self
Positive mental health such as optimism and self-confidence

<30%

of patients achieved within-normal QOL after first-line therapy^7§

From an analysis of 2,280 adults with major depressive disorder treated with a pharmacological therapy

41%

of patients with MDD discontinued treatment within 90 days⁸

From a retrospective claims analysis from 2013 to 2017

Defining normal QOL⁷

The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) scores within 10% of community norms are considered "within normal" QOLs. Because community norm samples have an average Q-LES-Q of 78.3 (Standard Deviation=11.3), a Q-LES-Q ≥ 70.47 is considered "within normal”.⁷

^‡Zimmerman 2006

Five hundred thirty-five psychiatric outpatients treated for an MDE at the Rhode Island Hospital Department of Psychiatry were given a 16-item questionnaire and asked to rate how important each factor was in determining remission.⁷

^§IsHak 2015

Post hoc QOL analysis of 2,280 patients enrolled in the STAR*D trial conducted in the United States. QOL was assessed using the 16-item Quality of Life Enjoyment and Satisfaction Questionnaire.⁷

Your MDD patients may have 6x greater remission likelihood with early improvement⁴

Approach to MDD Treatment

Today’s approach to MDD treatment may result in months to years of lost response and remission time

An analysis of 2 studies suggests that successive treatment failures correlate with lower remission rates and increased direct costs^9,10

Remission rates and direct costs by treatment step

Bar graph depicts an analysis of 2 studies that suggests successive treatment failures correlate with lower remission rates and increased direct
costs

^∥Rush AJ, et al, 2006 STAR*D Trial

Remission data was derived from the STAR*D trial. An analysis of adult patients with MDD from the STAR*D trial (N=3671) was conducted to compare the acute and longer-term outcomes associated with an initial antidepressant agent (Citalopram) for 12 weeks. Those who achieved remission (defined as a score of ≤7 on Hamilton Depression Rating Scale [HDRS]-17 or ≤5 on the Quick Inventory of Depressive Symptomatology Self Report 1 [QIDS-SR1]) or had a response (those with an adequate benefit [preferably remission] per clinician judgement) continued treatment for up to 12 months. Those who did not achieve remission or adequate benefit could switch to or add alternative pharmacotherapy and/or cognitive therapy in 3 additional sequential treatment steps.¹⁰

^¶Arnaud A, et al, 2021 Cost Data

Direct and employment-related costs were based on a retrospective analysis of Truven Health Analytics MarketScan® commercial medical and pharmacy claims data from 2013-2017 for US patients diagnosed with MDD (≥18 years of age).⁹

This comparison suggests that with every treatment tried and failed, the costs of MDD management is likely to rise

Antidepressant Use

Antidepressant use continues to rise in parallel to rates of MDEs with severe impairment

From 2015-2019^1,2,11

15%

increase in antidepressant use^11**

among commercially insured US adults

≈28%

increase in MDEs with severe impairment^2††

among US adults 18 and older

Defining Severe Impairment¹

Respondents were classified as having an MDE in the past 12 months if (1) they had at least 1 period of 2 weeks or longer in the past year when, for most of the day nearly every day, they felt depressed or lost interest or pleasure in daily activities; and (2) they also had problems with sleeping, eating, energy, concentration, self-worth, or having recurrent thoughts of death or recurrent suicidal ideation. Questions were based on diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which require the presence of 5 or more symptoms during the same 2-week period. Adults were classified as having an MDE with severe impairment if their depression caused severe problems with their ability to manage at home or at work, have relationships with others, or have a social life.¹

^**2020 Express Scripts Claims Analysis

From a 2020 claims analysis conducted by Express Scripts of 3.4 million individuals who filled at least one prescription for an antidepressant, which included medications used for the management of depression, anxiety, chronic pain, obsessive-compulsive disorder, post-traumatic stress disorder, and other indications.¹¹
^††2019 National Survey on Drug Use and Health

Survey was based on 50,731 completed interviews from the 2019 National Survey on Drug Use and Health for indicators of substance use and mental health among the civilian, noninstitutionalized population aged 18 or older in the United States.¹

Delaying effective treatment may lower patients’ likelihood of early response and remission^5,12,13

It’s time to reevaluate how we manage MDD

Resources

Sage Therapeutics and Biogen have partnered to develop a range of resources.

Journal of Managed Care & Specialty Pharmacy Resource Center

Payer Perspectives in Major Depressive Disorder (MDD)

Contact Us

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References: 1. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 national survey on drug use and health. https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR090120.htm. Accessed May 4, 2022. 2. Substance Abuse and Mental Health Services Administration. 2019 NSDUH detailed tables. https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables. Accessed May 4, 2022. 3. Ettman C, Cohen GH, Abdalla SM, et al. Persistent depressive symptoms during COVID-19: a national, population-representative, longitudinal study of U.S. adults. Lancet. 2022;5:100091. 4. Wagner S, Engel A, Engelmann J, et al. Early improvement as a resilience signal predicting later remission to antidepressant treatment in patients with major depressive disorder: systematic review and meta-analysis. J Psychiatr Res. 2017;94:96-106. 5. Ciudad A, Álvarez E, Roca M, et al. Early response and remission as predictors of a good outcome of a major depressive episode at 12-month follow-up: a prospective, longitudinal, observational study. J Clin Pyschiatry. 2012;73(2):185-191. 6. Zimmerman M, McGlinchey JB, Posternak MA, Friedman M, Attiullah N, Boerescu D. How should remission from depression be defined? The depressed patient’s perspective. Am J Psychiatry. 2006;163(1):148-150. 7. IsHak WW, Mirocha J, James D, et al. Quality of life in major depressive disorder before/after multiple steps of treatment and one-year follow-up. Manuscript. Acta Psychiatr Scand. 2014;1-20. 8. Arnaud A, Suthoff E, DeRienzo L, et al. Frequent treatment changes in the course of antidepressant therapy: real-world evidence of unmet needs in the pharmacotherapy of major depressive disorder. J Manag Care Spec Pharm. 2019;25(10):S49-S50. Abstract F11. 9. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163(11):1905-1917. 10. Arnaud A, Suthoff E, Tavares RM, Zhang X, Ravindranath AJ. The increasing economic burden with additional steps of pharmacotherapy in major depressive disorder. Pharmacoeconomics. 2021;3(6)9:691-706. 11. Express Scripts. America’s state of mind report. April 16, 2020. https://www.express-scripts.com/corporate/americas-state-of-mind-report. Accessed May 4, 2022. 12. Habert J, Katzman MA, Oluboka OJ, et al. Functional recovery in major depressive disorder: focus on early optimized treatment. Prim Care Companion CNS Disord. 2016;18(5). 13. Smagula SF, Butters MA, Anderson SJ, et al. Antidepressant response trajectories and associated clinical prognostic factors among older adults. JAMA Psychiatry. 2015;72(10):1021-1028.

The cost of MDD appears well managed, but the burden is greater than ever

It’s time to reevaluate how we manage MDD

Early improvement matters

For patients with MDD, returning to baseline is a primary goal for treatment6

Today’s approach to MDD treatment may result in months to years of lost response and remission time

Antidepressant use continues to rise in parallel to rates of MDEs with severe impairment

Resources

Contact Us

For patients with MDD, returning to baseline is a primary goal for treatment⁶