 Treatment Algorithms --
October 2007
 In This Issue...
Introduction:
Major depression affects more than 16 million people in the United States, making it the most prevalent psychiatric disorder. Paradoxically, major depression
is highly diagnosed for patients with borderline presentations and
underdiagnosed in some of the most serious cases. The majority of therapeutic
interventions consist of pharmacotherapy, though electroconvulsive therapy and
vagus nerve stimulation are used in certain cases. Although the market for
pharmaceuticals is mature and generics command substantial patient shares,
ample opportunity still exists for growth of branded therapies. For the last 20
years, the market has been dominated by selective serotonin reuptake inhibitors
(SSRIs) as first- and second-line therapies. Despite this dominance by SSRIs,
newer classes of drugs are poised to become premier players in the major
depression market.
Questions Answered in This Report:
- Lines of therapy: Initial lines of therapy are dominated
by SSRI or bupropion monotherapy, but selective serotonin and norepinephrine
reuptake inhibitors (SNRIs) are poised to capture market share. What factors
motivate physicians to choose SSRIs versus SNRIs? What are the major factors
affecting the latency before progression through subsequent lines of therapy?
How are the patients who take bupropion and benzodiazepines in the first line
different from those taking these agents in later lines of therapy? When do
physicians begin using adjunct therapies and why?
- Pathway to key therapies: A typical SSRI garners 29% of
its patients from the first line. Which SSRIs get their largest fraction of
patients in each line of therapy and why? How are SNRIs and bupropion used similarly
or differently? Which key therapy has the largest fraction of its patients
arising from third line and what key leverage points can be used to increase
its share?
- Physician behavior: While primary care physicians (PCPs)
and psychiatrists typically prescribe SSRIs initially, specialists are
increasingly turning to other classes of drugs in later lines. Specifically,
psychiatrists and PCPs view the role of SNRIs and antipsychotics much
differently. What comorbidities are most common with major depression, and
which drugs differentiate themselves best with respect to these comorbidities?
Who prescribes antipsychotics as adjunct therapies and why? How can
antipsychotics best position themselves for use by psychiatrists, and how does this
strategy differ for PCPs?
- Forecast: Generic availability of Effexor XR (venlafaxine)
will dramatically affect physician use of SNRIs by making this class more
available to cost-conscious patients. In which line of therapy will generic
SNRIs become most prominent? How will off-label use of venlafaxine
affect the patient shares of other drugs? Are physicians aware of Pristiq,
Valdoxan, or Gepirone ER? How will clinical trials for these emerging therapies
affect their labeling status? And how will this labeling status affect the
patient shares these agents and therefore of existing therapies?
Includes:
Primary research: Quantitative results from our
survey of 153 physicians (76 psychiatrists and 77 PCPs):
- Physician opinion on how drug use differs by patient severity.
- Most influential drug attributes when physicians choose between
agents.
- Anticipated changes in the line of therapy in which physicians
use key agents.
Primary patient-level data: Quantitative findings
from our analysis of data covering 55 million lives from more than 80
geographically diverse U.S. HMOs:
- Quantified lines of therapy analysis showing exact share of each
agent in each line of therapy, including rate of progression between lines and
length of time patients are on each line.
- Progression flowcharts through one year of treatment for newly
diagnosed patients receiving each of the following first-line agents: Lexapro,
sertraline, fluoxetine, paroxetine, citalopram, bupropion, Effexor, Cymbalta,
benzodiazepines, modified cyclics, tricyclic agents, lithium, fluvoxamine,
Symbyax, mirtazapine, Seroquel, Zyprexa, Abilify, and other atypical
antipsychotics.
- Flowcharts tracking the preceding therapy patterns for patients
taking each of the following key therapies: Lexapro, sertraline, citalopram,
fluoxetine, paroxetine, Effexor, Cymbalta, bupropion, Seroquel, Zyprexa,
Abilify, mirtazapine, and Symbyax.
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