A retrospective chart review study to quantify the monthly medical resource use and costs of treating patients with treatment resistant depression in the United Kingdom

Figures & data

Table 1. Definition of health states.

Health state	Definition
MDE	Patients with TRD who experience moderate to severe symptoms of major depressive disorder and failed to respond to at least two different AD treatments of adequate dosage and duration in the current MDE. Adequate dose is considered the maximal dose accepted by the BNF, while an appropriate duration is a minimum of 4 weeks. This also includes relapse, a return of depressive symptoms following the onset of remission but before fulfilling the criteria for recovery.
Remission	A period during which the patient is either symptom free or has only minimal symptoms for a significant period occurring no more than 6 months. The period of remission may end with either relapse or recovery.
Recovery	An extended asymptomatic phase, achieved after a patient remains in relapse-free remission beyond 6 months (corresponding to the end of the current depressive episode) so that continued well-being may be expected (with or without continuing treatment).

Abbreviations. MDE, Major depressive episode; TRD, Treatment resistant depression; AD, Antidepressant drug; BNF, British National Formulary.

Figure 1. Outcome definitions plotted against time in months.

Table 2. Demographic details of patients with MDD during the management of TRD.

Characteristic	MDE (n = 295)	Remission (n = 190)	Recovery (n = 113)
Age (years), mean (SD)	43.3 (13.6)	42.6 (14.0)	40.7 (14.6)
Female (%)	60.3	57.9	59.3
BMI (kg/m^2), mean (SD)	25.7 (4.3)	27.0 (3.9)	25.1 (3.8)
Employed, full- or part-time (%)	26.1	33.7	34.5
Unemployed (%)	32.8	31.6	33.6
Retired (%)	9.2	9.0	9.7
Time from diagnosis to index date (months), mean (SD)	62.1 (89.2)	60.0 (94.5)	48.8 (79.6)
Duration of follow up (days), mean (SD)	802 (91)	804 (74)	805 (62)
Prior MDE (%)	51.3	50.0	45.5
Anxiety disorder	36.3	35.8	37.2
Stress	27.8	27.9	29.2
Alcoholism	18.0	15.3	8.0
Sleep disorder	16.3	15.3	15.0
Personality disorder	13.9	14.2	9.7
Obesity	13.2	11.6	15.0
Substance abuse	11.5	12.1	12.4

Abbreviations. MDD, Major depressive disorder; TRD, Treatment resistant depression; MDE, Major depressive episode; SD, Standard deviation; BMI, Body mass index.

Table 3. Mean (SD) number of events encountered in each health state per month (28 days) during the management of TRD.

Event	MDE	Remission	Recovery
Primary care visits	0.29 (0.48)	0.19 (0.46)	0.09 (0.24)
For depression	0.25 (0.45)	0.15 (0.29)	0.04 (0.08)
GP visit	0.31 (0.52)	0.20 (0.41)	0.10 (0.26)
Nurse visit	0.03 (0.18)	0.05 (0.16)	0.06 (0.18)
Specialist visits	0.36 (0.23)	0.21 (0.22)	0.21 (0.34)
Suicide attempts	0.05 (0.13)	0.01 (0.07)	0.00 (0.02)
CRHTT events	0.13 (0.43)	0.01 (0.05)	0.00 (0.03)
CRHTT days	1.70 (3.54)	0.09 (0.41)	0.10 (0.65)
Hospitalization (nights)	1.40 (4.15)	0.16 (1.18)	0.04 (0.28)

Abbreviations. GP, General practitioner; CRHTT, Crisis Resolution and Home Treatment Team; SD, Standard deviation; TRD, Treatment resistant depression; MDE, Major depressive episode.

Table 4. Drugs prescribed to >5% of patients with TRD over a 2 year follow up period (%).

Drug	MDE (n = 342)	Remission (n = 219)	Recovery (n = 113)
Mirtazapine	23.1	20.6	23.9
Venlafaxine	16.1	16.0	7.1
Quetiapine	13.7	14.6	12.4
Aripiprazole	13.0	13.6	10.6
Duloxetine	11.1	11.9	8.8
Zopiclone	8.7	5.5	1.8
Sertraline	9.1	6.8	7.1
Citalopram	8.2	1.4	2.7
Lithium	8.8	10.5	6.2
Fluoxetine	5.6	2.3	2.7

Abbreviations. TRD, Treatment resistant depression; MDE, Major depressive episode.

Table 5. Mean (SD) number of non-drug treatment sessions per month (28 days) in each health state during the management of TRD.

Session	MDE	Remission	Recovery
Occupational therapy	0.12 (0.68)	0.05 (0.34)	0.00 (0.00)
CBT	0.11 (0.42)	0.12 (0.45)	0.04 (0.16)
Counselling	0.21 (0.90)	0.05 (0.25)	0.01 (0.08)
Psychotherapy	0.06 (0.31)	0.05 (0.31)	0.01 (0.06)
Mindfulness therapy	0.14 (0.94)	0.01 (0.10)	0.00 (0.01)
ECT	0.03 (0.36)	0.01 (0.11)	0.00 (0.00)
Health coaching	0.00 (0.07)	0.00 (0.07)	0.00 (0.00)
Behavioural activation therapy	0.01 (0.14)	0.00 (0.06)	0.01 (0.07)

Abbreviations. MDE, Major depressive episode; CBT, Cognitive behavioural therapy; ECT, Electroconvulsive therapy; TRD, Treatment resistant depression.

Figure 2. Mean HCRU costs by health state (£) per patient per month (28 days) during the management of TRD.

Table 6. Mean (SD) cost per patient per month (28 days) of non-drug treatment sessions in each health state during the management of TRD.

Session	MDE	Remission	Recovery
Primary care visits	10.82 (17.93)	7.12 (16.86)	3.44 (8.84)
Specialist visits	52.32 (77.09)	30.71 (32.81)	30.18 (49.43)
Hospitalizations (all days)	380.18 (1121.88)	42.42 (315.32)	11.93 (76.70)
ED	2.48 (9.47)	0.14 (1.54)	0.15 (1.12)
ICU	22.65 (224.05)	0.00 (0)	0.00 (0)
Psychiatric ward	16.50 (53.88)	2.41 (21.66)	0.62 (4.83)
CRHTT use	326.31 (678.86)	18.09 (79.2)	18.43 (124.3)
Occupational therapy	72.72 (403.21)	29.68 (202.64)	0.00 (0)
CBT	10.84 (41.90)	12.38 (44.64)	4.03 (16.15)
Counselling	9.23 (39.41)	2.09 (10.85)	0.56 (3.43)
Psychotherapy	8.51 (44.66)	7.24 (45.50)	0.85 (8.84)
Mindfulness therapy	24.52 (164.76)	1.43 (16.87)	0.19 (1.96)
ECT	6.19 (75.39)	1.90 (22.95)	0.00 (0)
Health coaching	0.41 (5.85)	0.42 (6.27)	0.00 (0)
Behavioural activation therapy	0.22 (2.44)	0.07 (1.10)	0.11 (1.17)

Abbreviations. MDE, Major depressive episode; ED, Emergency department; ICU, Intensive care unit; CRHTT, Crisis Resolution and Home Treatment Team; CBT, Cognitive behavioural therapy; ECT, Electroconvulsive therapy; TRD, Treatment resistant depression.

List of non-drug resources, unit costs and source.

Resource	Unit cost	Source
Primary care consultation	£37.00	Curtis and Burns^30
Specialist psychiatrist consultation	£147.00	Curtis and Burns^30
CRHTT (cost per day)	£192.00	Curtis and Burns^30
ECT (cost per session)	£211.00	McLoughlin et al.^31
TMS (cost per session)	£60.17	McLoughlin et al.^31
Psychotherapy (cost per session)	£146.00	Nightingale Hospital^32
Occupational therapy/vocational rehabilitation (cost per session)	£596.00	Curtis and Burns^30
CBT (cost per session)	£100.00	Curtis and Burns^30
Mindfulness therapy (cost per therapy)	£175.00	Curtis and Burns^30
Behavioural activation therapy (cost per session)	£17.00	Curtis and Burns^30
Counselling (cost per session)	£44.00	Curtis^33
Health coach (cost per session)	£85.63	Kibble et al.^34
Inpatient hospitalisation, no admission to psychiatric ward (cost per night)	£266.12	Rayner et al.^35
Inpatient hospitalisation, admission to psychiatric ward (cost per night)	£404.00	Curtis and Burns^30
Hospitalisation admission via ER	£146.00	Department of Health & Social Care^36
Hospitalisation admission to ICU (cost per night)	£1328.00	Department of Health & Social Care^36

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