Disclosures Christer Allgulander

(1)

How Patients With Generalized Anxiety

Disorder (GAD) Are Treated in Specialized

Care: A Pharmacoepidemiological Case

Register Study in Sweden

Christer Allgulander MD, Karolinska Institutet, Sweden Jan Kowalski – Statistics Consultant

Rebecka Sandelin – Outcomes Research Manager – Pfizer Sweden Ewa Ahnemark – Medical Adviser – Pfizer Sweden

Disclosures

Christer Allgulander

Speaker: Eli Lilly Sweden AB, Pfizer AB

Advisory Board: Pfizer AB

(2)

Background I

• GAD is the most common anxiety disorder in health care.

• GAD/depression was found in 23% of patients in

Swedish primary care.

• GAD and anxiety are risk factors in cardiovascular,

cerebrovascular and endocrine diseases and in chronic

obstructive pulmonary disease.

• GAD impairs the patient’s capacity for work, leisure

activities and relations, and induces high health care

costs.

Allgulander C, Nilsson B. Lt 2003;100:832-8

Allgulander C. Psychiatr Clin N America 2009;32:611-28

Background II

Medications approved by the Swedish Medicinal Products

Agency for treating GAD:

•paroxetine, escitalopram

•venlafaxine, duloxetine

•buspirone*

•pregabalin

Evidence-based psychotherapy for GAD according to the

Swedish Council on Technology Assessment in Health

Care:

(3)

Purpose

To determine which medications are used to treat GAD

patients in specialized care, associated costs, and

associated psychiatric and somatic comorbidity.

Methods

All patients in the Swedish National Patient Register with a primary diagnosis of GAD (ICD-10 F41.1) in specialized care in 2006. All prescriptions delivered in the 12 months following diagnosis, as

recorded in the Prescribed Drug Register.

Record linkage by means of personal identification numbers An anonymous data file for statistical analyses.

Approval by the Karolinska Institutet ethics review board. Financed by Pfizer AB, Sweden.

(4)

Study population

31 Dec 2007 31 Dec 2006 1 Jan 2006 Index diagnosis

Study population

• 3 701 patients (1 303 men, 2 398 women)

• Mean age 44 years (range 6-94; SD=16)

• 7 005 outpatient visits recorded

• 358 inpatient admissions

• 81 704 prescriptions delivered for psychoactive

medications to 3 352 patients (90% of the patients)

(5)

Medication groups

SSRI Escitalopram, paroxetine, sertraline, citalopram, fluoxetine, fluvoxamine

SNRI* Venlafaxine, duloxetine, mirtazapine, mianserin

Antiepileptics Pregabalin, gabapentin, lamotrigine

TCA Clomipramine, nortriptyline, amitriptyline, trimipramine

Phenothiazines Chlorpromazine, haloperidol, flufenazine,

levomepromazine, perfenazine, prochlorperazine, flupentixol, chlorprotixene, zuclopentixol

Antipsychotics Quetiapine, olanzapine, risperidone, ziprasidone, aripiprazole, sertindole, clozapine

BZ-anxiolytics Diazepam, oxazepam, alprazolam, lorazepam

BZ-hypnotics Flunitrazepam, nitrazepam, triazolam, zaleplon, zopiclone, zolpidem

Antihistamines Propiomazine, alimemazine, promethazine, hydroxizine

Other Buspirone

*Includes noradrenergic and specific serotonergic antidepressants

(6)

Outpatient and inpatient care in 2006

(N=3 701)

Outpatient care n=3 461 (94%) Inpatient care n=358 (10%)

Outpatient and inpatient care n=147(4%)

Common additional psychiatric

diagnoses (N)

Depressive syndromes 406

Other anxiety disorders 284 Personality disorders 204 Substance-induced disorders 183 Neurodevelopmental disorders 111 Obsessive compulsive disorder 73 Dissociative/somatoform/other neurotic disorders 32 Manic episode, bipolar disorder 24

Eating disorders 23

(7)

Somatic comorbid diagnoses (N)

Hypertension

20 Diabetes

19 Joint diseases

19 Ischemic heart disease

13 Malignant tumors

9 Chronic pulmonary disease

7 Thyroid disease

5 N=3 701

Distribution of delivered prescriptions by medication

type and treatment duration

6 8 9 12 13 38 39 46 47 52 0 20 40 60 80 100 Buspirone Phenothiazines TCAs Antipsychotics Antiepileptics SNRI Hypnotics Antihistamines BZ-anxiolytics SSRI

Proportion (%) of patients delivered prescriptions 223 190 254 239 192 332 280 256 319 302 0 50 100 150 200 250 300 350

Mean number of days treated

(8)

Proportion of patients with prescriptions during the first

3 months and last 3 months, by medication type

0 10 20 30 40 50 60 70 Buspirone Phenothiazines TCA Antipsychotics Antiepileptics SNRI Hypnotics Antihistamines BZ-anxiolytics SSRI % of patients (n=3 701) First 3 months Last 3 months

Multiple prescriptions for psychoactive

medications

0 100 200 300 400 500 600 SSRI/SNRI only +hypnotics +anxiolytics +anxiolytics +hypnotics +antipsychotics

(9)

Direct costs for specialized care during

a 12-month period

Cost per patient

SEK

US$

Outpatient care

7 698

1 078

Inpatient care

92 152

12 905

Medications

5 520

773

3 701 patients with a primary GAD diagnosis

Total cost SEK 78 million (US$ 11 million) over 12 months

1 $US = 7.1411 SEK

Limitations

– The study period is limited to 12 months – Under reporting of cases with GAD – Varying accuracy in diagnostic procedures – Selection of severe GAD cases to specialist care – Costs under-estimated due to:

• Under reporting from private practitioners

• Indirect costs not included: sick leave, family burden, etc. – Comorbidity estimates are based only on registered diagnoses

(10)

Conclusions I

Overall, approximately:

– 75% of patients were treated with SSRI/SNRI.

– 50% of patients were treated with benzodiazepine anxiolytics for long periods.

– 40% of patients were treated with hypnotics.

– 10% of patients were treated with phenothiazines or antipsychotics.

Conclusions II

– High medication utilization indicates a considerable disease burden. – Comorbidity partly explains the need for multiple medications. – Insomnia and initial anxiety aggravation induced by SSRI/SNRIs may

have necessitated adjunct anxiolytics and hypnotics at initiation of treatment.

– The reasons for maintenance treatment with benzodiazepines in the elderly needs to be studied.

– Early diagnosis and intervention are likely to reduce cost, particularly to prevent inpatient admission.