OBJECTIVES: When patients do not respond to their initial
treatment, the physician can increase the initial dose, switch to
another treatment or add another treatment. This analysis aims
at comparing the different strategies after initiation of escitalopram
10mg in patients treated for Major Depressive Disorder
(MDD). METHODS: Adult MDD patients initiated on escitalopram
10mg, who either increased to 20mg (dose-increased
patients) or switched to (switchers) or were added another anti
depressant (combination patients), were identified in the PharMetrics
US claims Database (2003-2006). Patients with early
dose increase (before 14 days) were excluded as it was considered
as a scheduled dose titration. Patients’ characteristics at
treatment initiation and treatment outcomes three months after
treatment initiation were compared: treatment persistence or
change, health care resource use and associated costs. Multivariate
regression analyses were performed to adjust for patient
characteristics and baseline resource use. RESULTS: A total of
8811 patients started with escitalopram 10 mg of which 51%
increased to 20 mg, 29% switched and 20% had a combination.
Mean time to treatment change was 42 days for dose
increase, 36 days for switch (p < 0.001) and 30 days for combination (p < 0.001). Three months after treatment initiation, dose-increased patients had higher 3-month persistence compared with switchers or combination patients, even when considering a time-event interaction. Switchers and combination patients had a higher rate of subsequent/second switch and/or combination (17.7% and 71.1% respectively), compared with dose-increased patients (9.6%). Costs of both switchers and combination patients were higher than those of dose-increased patients (respectively: +US$124, adjusted RR = 1.1, 95%CI = [1.0-1.2]; and +US$1060, adjusted RR = 1.3, 95%CI = [1.2- 1.5]). CONCLUSIONS: Increasing the dose of escitalopram from 10 to 20mg was associated with fewer further changes in treatment and with lower costs than switching or adding another antidepressant. For patients who do not respond well to their initial dose, dose increase should be considered before any other strategy