Biomedical subjects

T R Hylan

Publications and source records attributed to T R Hylan.

23 records · Page 2Linked to original sources

PubMedDate not supplied

Economic consequences of selective serotonin reuptake inhibitor use with drugs also metabolized by the cytochrome P-450 system.

Administration of selective serotonin reuptake inhibitors (SSRIs) may increase plasma concentrations of concomitant medications that are also metabolized by the cytochrome P-450 system (CYP-450), in particular by the 2D6 and 3A4 isoenzymes. This may lead to side effects or other clinical events that might be expected to incur higher health-care expenditures. The purpose of this study was to assess whether there was a difference in expenditures during the first 90 days of SSRI therapy with paroxetine or sertraline versus fluoxetine in patients who were also receiving a stable dosage of a nonpsychiatric drug also metabolized by the CYP-450 2D6 or 3A4 isoenzyme systems. A sample of 2445 patients who initiated therapy with an SSRI while receiving a stable dosage of a nonpsychiatric drug was obtained from a private insurance claims database. Multivariate regression techniques were used to estimate total health-care expenditures in the first 90 days after receiving a prescription for an SSRI. After adjusting for nonrandom SSRI prescription patterns and controlling for observable and unobservable characteristics that might correlate with SSRI selection, total health-care expenditures were 95% higher for patients initiating SSRI therapy with sertraline or paroxetine compared with fluoxetine. Results suggest that there are cost differences between SSRIs during concomitant therapy with drugs also metabolized by the CYP-450 system. To determine whether there are additional differences in expenditures across SSRIs, future research should focus on (1) simultaneous initiation of SSRI therapy and a nonpsychiatric drug also metabolized by the CYP-450 enzyme system, and (2) addition of nonpsychiatric drug therapy to stable SSRI therapy. Relationships between additional expenditures, drug interactions, and clinical outcomes should also be assessed directly using medical records and patient interview data that are not available in claims-based files.

Adolescent↗

PubMedDate not supplied

Recovery from depression, work productivity, and health care costs among primary care patients.

We describe a secondary analysis of data from a randomized trial conducted at seven primary care clinics of a Seattle area HMO. Adults with major depression (n=290) beginning antidepressant treatment completed structured interviews at baseline, 1, 3, 6, 9, 12, 18, and 24 months. Interviews examined clinical outcomes (Hamilton Depression Rating Scale and depression module of the Structured Clinical Interview for DSM-IIIR), employment status, and work days missed due to illness. Medical comorbidity was assessed using computerized pharmacy data, and medical costs were assessed using the HMO's computerized accounting data. Using data from the 12-month assessment, patients were classified as remitted (41%), improved but not remitted (47%), and persistently depressed (12%). After adjustment for depression severity and medical comorbidity at baseline, patients with greater clinical improvement were more likely to maintain paid employment (P=.007) and reported fewer days missed from work due to illness (P<.001). Patients with better 12-month clinical outcomes had marginally lower health care costs during the second year of follow-up (P=.06). We conclude that recovery from depression is associated with significant reductions in work disability and possible reductions in health care costs. Although observational data cannot definitively prove any causal relationships, these longitudinal results strengthen previous findings regarding the economic burden of depression on employers and health insurers.

Adolescent↗

PubMedDate not supplied

SSRI antidepressant use patterns and their relation to clinical global impression scores: a naturalistic study.

BACKGROUND: A cascade of events follows initial antidepressant selection which includes the subsequent antidepressant use pattern, resultant clinical outcomes, and associated health care expenditures. PURPOSE: The purpose of this study using data from a clinical practice setting was to test whether the pattern of antidepressant use was correlated with patients' treatment response as measured by the score on the Clinical Global Impression-Improvement scale. DATA AND METHODS: A retrospective dataset of patients who initiated therapy on fluoxetine, fluvoxamine, paroxetine, or sertraline in a primary care setting in Spain was used. A Cox proportional hazard analysis was used to predict the likelihood of treatment response based upon the pattern of initial antidepressant use, while minimizing the influence of other factors. RESULTS: After controlling for other observed baseline characteristics including initial disease severity, (a) patients who remained on their initial antidepressant therapy for at least 2 months with no switching, augmentation, or upward dose titration were 1.63 times more likely to experience a treatment response than patients who had an adjustment to therapy; and (b) patients who initiated therapy on sertraline were 0.46 times as likely to experience a treatment response as patients who initiated therapy on the most common study antidepressant, fluoxetine. CONCLUSION: The pattern of antidepressant use is an important determinant of treatment response among patients initiating therapy on the newer antidepressants in clinical practice.

Adult↗

PubMedDate not supplied

Controlling for systematic selection in retrospective analyses: an application to fluoxetine and sertraline prescribing in the United Kingdom.

BACKGROUND: Criticism has been made of observational studies in clinical practice because of their failure to control for unobserved factors that correlate with both initial treatment selection and observed outcomes. METHOD: A two-stage statistical model was applied to data obtained from a large general practitioner medical records database (DIN-LINK) to estimate the effect of initial antidepressant selection on the duration of antidepressant therapy and on the likelihood of being prescribed an average daily dose above the minimum recommended dose. The statistical model controlled for unobserved factors correlated with initial treatment selection and the observed outcomes as well as for observed confounders. RESULTS: Unobserved factors correlated with treatment selection were not a statistically significant determinant of the number of days of antidepressant therapy. However, unobserved factors correlated with treatment selection were a statistically significant determinant of the likelihood of receiving an average dose during therapy greater than the minimum recommended. After controlling for relevant confounders, those patients who began treatment with sertraline as opposed to fluoxetine had fewer days of antidepressant therapy and were more likely to receive average doses greater than the minimum recommended during therapy. CONCLUSION: Unobserved factors correlated with treatment selection can impact outcomes in observational studies and should be tested and controlled for whenever possible.

Journal Article↗

PubMedDate not supplied

[Pattern of usage of new antidepressants in clinical practice].

INTRODUCTION: Data from naturalistic studies have reported differences in the clinical use of antidepressants referring to the need for adjusting doses, treatment duration, tolerability and use of concomitant medication. These differences could be considered as an indicator of the effectiveness of antidepressants in clinical practice settings. OBJECTIVES: It is a naturalistic, retrospective, observational study which objective is to evaluate and compare the pattern of antidepressant use (fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine) and to establish if there is a relation between the different pattern of use and the effectiveness of them. DATA AND METHODS: A retrospective dataset of patients who initiated therapy on fluoxetine, fluvoxamine, paroxetine, sertraline, or venlafaxine with a follow-up period of 6 months was used. Information about clinical characteristics of patients and antidepressant pattern of use were collected. Pattern of antidepressant use were defined as: "initial doses", "upward dose titration", "augmentation strategy", "switching" and "early interruption of treatment". The efficacy of the therapy was assessed by the CGI-improvement. RESULTS: Fluoxetine was the antidepressant more associated with a statistical significance (p = 0.001) to an stable pattern of use (initial doses without upward dose titration, switching or augmentation). After controlling for other observed baseline characteristics, patients who remained on their initial antidepressant therapy, with a stable pattern of use were 1.61 times more likely than patients who had an adjustment to therapy to experience a treatment response. Patients who initiated treatment with sertraline or venlafaxine were 2.155 and 4.831 times less likely, respectively, to experience a response relative to patients who initiated therapy on fluoxetine. CONCLUSIONS: The need to upward dose titration, switching or augmentation in the treatment could be indicated a worse therapeutic control of the symptoms. Patients treated with fluoxetine are in a stable pattern of use more likely than patients in the other antidepressants, this fact is related with better global therapeutic results.

Adult↗