Expenditures associated with dose titration at initiation of therapy in patients with major depressive disorder: a retrospective analysis of a large managed care claims database.

OBJECTIVE.: Although selective serotonin reuptake inhibitors (SSRIs) are considered cost-effective medications for patients with major depressive disorder (MDD), significant dosage adjustments are often necessary when treatment is initiated. Our study was conducted to examine whether dose titration for SSRIs at initiation of therapy was associated with a greater use of health care resources and higher costs. STUDY DESIGN.: A retrospective database analysis was conducted. METHODS.: A nationally representative cohort of individuals with MDD was identified in a large managed care claims database between January 1, 2004, and December 31, 2006. A study-specific titration algorithm was used to identify patients who underwent dose titration, compared with those who did not, within the first eight weeks of initiating SSRI therapy. We calculated propensity scores and identified a 1:1 matched cohort of titration versus non-titration patients. We used univariate and multivariate statistical tests to compare the mean number of therapeutic days, health care service utilization, and expenditures between the two groups during the first eight weeks (56 days) of treatment and six months (180 days) after treatment began. RESULTS.: Over the first eight weeks, the titration cohort had a 32% decrease in the adjusted mean number of therapeutic days (38 vs. 56, respectively; P < 0.001), a 50% increase in depression-related outpatient visits (1.8 vs. 1.2; P < 0.001), a 38% increase in depression-related outpatient costs ($137 vs. $81; P ≤ 0.001), an increase in antidepressant pharmacy costs ($139 vs. $61; P < 0.001), and a 64% increase in psychiatric visits (0.69 vs. 0.42; P = 0.001), compared with the matched non-titration cohort. These differences were consistent among individual SSRI groups as well as during the six-month period. CONCLUSION.: Patients undergoing dose titration of SSRIs at the beginning of therapy consumed more medical resources and spent more days receiving a subtherapeutic dose than a comparable control group without dose titration. Differences in the utilization of resources were consistent with increased patient monitoring in the titration group; however, the added benefit of titration could not be assessed with this database.