Abstract
The potential of personalized medicine to transform the treatment of mood disorders has been widely touted in psychiatry, but has not been quantified. We estimated the costs and benefits of a putative pharmacogenetic test for antidepressant response in the treatment of major depressive disorder (MDD) from the societal perspective. Specifically, we performed cost-effectiveness analyses using state-transition probability models incorporating probabilities from the multicenter STAR*D effectiveness study of MDD. Costs and quality-adjusted life years (QALYs) were compared for sequential antidepressant trials, with or without guidance from a pharmacogenetic test for differential response to selective serotonin reuptake inhibitors (SSRIs). Likely SSRI responders received an SSRI, whereas likely nonresponders received the norepinephrine/dopamine reuptake inhibitor bupropion. For a 40-year old with MDD, applying the pharmacogenetic test and using the non-SSRI bupropion for those at higher risk for nonresponse cost $93 520 per additional QALY compared with treating all patients with an SSRI first and switching sequentially in the case of nonremission. Cost per QALY dropped below $50 000 for tests with remission rate ratios as low as 1.5, corresponding to odds ratios ∼1.8–2.0. Tests for differential antidepressant response could thus become cost effective under certain circumstances. These circumstances, particularly availability of alternative treatment strategies and test effect sizes, can be estimated and should be considered before these tests are broadly applied in clinical settings.
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Acknowledgements
This work was supported by NIMH K23-MH67060, NARSAD and the Sydney R Baer, Jr Foundation, and the Bowman Family Foundation (Dr Perlis) and NIMH R01-MH6194 (Dr Wang). No pharmaceutical company was involved in any way in initiating, conducting, or supporting this research.
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Roy Perlis
Research Support: Eli Lilly & Company
Advisory/Consulting: AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Company, Pfizer Inc., Proteus
Speaking: AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Company, GlaxoSmithKline, Pfizer Inc.
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Jordan Smoller
Dr Smoller has received honoraria from Hoffman-La Roche, Inc., and has served on an advisory board for Roche Diagnostics Corporation. He has received research funding from the National Institute of Mental Health and the National Alliance for Research in Schizophrenia and Depression.
The other authors have no financial competing interests to disclose.
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Perlis, R., Patrick, A., Smoller, J. et al. When is Pharmacogenetic Testing for Antidepressant Response Ready for the Clinic? A Cost-effectiveness Analysis Based on Data from the STAR*D Study. Neuropsychopharmacol 34, 2227–2236 (2009). https://doi.org/10.1038/npp.2009.50
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DOI: https://doi.org/10.1038/npp.2009.50
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