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Economic evaluation of first-line treatments for depression in Turkey

April 22, 2015

Economic evaluation of first-line treatments for depression in Turkey:a cost-effectiveness model


To investigate the cost-effectiveness of escitalopram compared with citalopram and venlafaxine over a 6-month time horizon in the treatment perspectives.


Escitalopram is the therapeutically active S-enantiomer of citalopram. While the recommended dose of escitalopram is half that of citalopram, research has indicated that escitalopram, even at half the citalopram dose, is approximately twice as potent in serotonin uptake inhibitory activity. This difference in potency may come apparent in a significantly higher remission rate. The higher remission rate (both at recommended dose and at double dose for non-responding patients) was the greatest driver of the decision analytic model.

As in all decision analytic models, different sources of data were used which may have affected the internal validity of the model. We attempted to reduce these potential biases by conducting a systematic review of published literature and by building the model on local data collected through a survey of psychiatrists to determine clinical management patterns, resource utilisation, and loss of productivity and not by relying solely on expert opinion.

In our economic analysis we used the meta-analysis by Einarson for the main outcome. The meta-analysis, however, was carried out on clinical data derived from patients in the first line of depression in primary care. As GPs in Turkey are very restricted in prescribing SSRIs or SNRIs, we assumed that the data on these patients would be similar to patients who would get a prescription for a first-line antidepressant from a specialist in Turkey.

Another limitation was the absence of direct comparative clinical trial data between escitalopram, citalopram and venlafaxine. As indirect comparisons are sometimes criticized, we preferred to carry out parallel analyses that still permit the reader to conduct an indirect comparison based on the given results.

All assumptions, as well as the uncertainty in estimating the variables, were tested in extensive sensitivity analyses to verify the validity of the conclusions, estimates and different hypotheses. The results confirmed that no variable significantly affected the primary outcome and costs coming from the model. The results reported in this study are consistent with previous evaluations of cost-effectiveness of escitalopram.

We were unable to compare our results with other cost- effectiveness studies of antidepressant treatment in Turkey, as no other studies could be found in published literature.

Compared to other countries, antidepressant drug costs in Turkey represent a relatively large fraction of total costs. If remission is not achieved within the first two months, higher costs are incurred as the result of more intensive patient management (additional visits to adjust or change the treatment), and eventual hospitalisations.

Economic evaluation of first-line treatments for depression in Turkey