The prospective, 24-week assessment of cost-efficacy of and compliance to antidepressant medications in a rural setting (PACECAR) study

BACKGROUND Anxiety and depression are common mental health disorders that are responsible for considerable societal burden. There are no data on cost-efficacy and medication compliance related to the treatment of these disorders in rural India. MATERIALS AND METHODS All consenting adults (n = 455) diagnosed with generalized anxiety or (unipolar) depressive disorders in Suttur village, Karnataka, were treated with open-label fluoxetine (20-60 mg/day), sertraline (50-150 mg/day), escitalopram (10-20 mg/day), desvenlafaxine (50-150 mg/day), duloxetine (30-90 mg/day), amitriptyline (75-150 mg/day), or clomipramine (75-150 mg/day) in a structured, monotherapy dosing plan. The study was nonrandomized and otherwise naturalistic. Patients were followed up every 4 weeks for 24 weeks. Study discontinuation was defined as medication noncompliance for 3 or more days or withdrawal due to treatment nonresponse. RESULTS There was substantial discontinuation (34.5%) in the first 4 weeks; 55.4% had discontinued by 12 weeks. Subsequently, only 11.2% discontinued treatment. Only 33.4% of the subjects tolerated the treatment, responded to it, and remained compliant for 24 weeks. Such successful completion was highest for escitalopram and desvenlafaxine (46%-47%) and lowest for clomipramine and amitriptyline (10%-14%). Adverse events were the most common reason for noncompliance with clomipramine and amitriptyline (45%-46%); the experience of sufficient improvement was the most common reason for noncompliance with the remaining drugs (28%-49%). Whereas the average cost of efficacious treatment for a continuous period of 24 weeks was lowest for fluoxetine, an examination of the cost-efficacy tradeoff suggested maximum advantage for escitalopram, sertraline, and desvenlafaxine. The cost-efficacy profile for amitriptyline and clomipramine was poor. CONCLUSIONS Reasons for noncompliance vary by drug class and need to be considered when prescribing antidepressant drugs. Escitalopram, sertraline, and desvenlafaxine perhaps have the most favorable 24-week cost-efficacy profile; tricyclics are poorly tolerated. Rural subjects need to be educated that treatment must be continued even after improvement is established.