Stoppen Met Antidepressiva
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Department of Pharmaceutical Sciences
Antidepressivagebruikers stoppen er mee
3 Juli 2009Dr. E.R. Heerdink
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Department of Pharmaceutical Sciences
Rob Heerdink
Pharmacoepidemiology & PharmacotherapyUtrecht Institute for Pharmaceutical SciencesUniversiteit UtrechtThe Netherlands
www.pharm.uu.nl/epithera
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Department of Pharmaceutical Sciences
Depression in The Netherlands
Year prevalence depression: – 6% of the population – 900.000 patients per year
Average episode 6 months– In 70-80% relapse– 15-20% is chronically depressed
Depression related costs:– 660 Mil € direct– 3.8 Bil € indirect per year
Trimbos Instituut 2006; Andrade L et al , Bull World Health Organ 78:413-426
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Department of Pharmaceutical Sciences
0,0
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1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Prevalence SSRI
Incidence SSRI
Prevalence TCAIncidence TCA
Indexed prevalence and incidence per year of antidepressant use during 1992-2001 (1992=1).
Meijer et al. Eur J Clin Pharmacol (2004) 60: 57–61
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Department of Pharmaceutical Sciences
Are Subjects in Pharmacological Treatment Trials of Depression Representative of Patients in Routine Clinical Practice?Mark Zimmerman, M.D., Jill I. Mattia, Ph.D., and Michael A. Posternak, M.D
Am J Psychiatry 159:469-473, March 2002
‘Of 346 patients with ‘major depression’ only 14% are eligible according to inclusioncriteria for trials with antidepressants’
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Department of Pharmaceutical Sciences
Depression treatment guidelines
1st episode: At least 6 months continued use following disappearance of symptoms
relapse or chronic:At least 1 year continued use following remission
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937.020
Gip databank 2007
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937.020
702.765
Meijer et al 2004
234.255Chronic users
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937.020
702.765
Van Geffen et al 2008
30.200primary defaulting
+
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937.020
702.765
541.130
Van Geffen et al 2008
161.636only 1 prescription
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937.020
702.765
541.130
189.750
Van Geffen et al 2008
175.690< 6 months
175.690>12 months
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937.020
702.765
541.130
189.750
68.310Van Geffen et al 2008
121.440no tapering
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937.020
68.310
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Department of Pharmaceutical Sciences
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Department of Pharmaceutical Sciences
937.020
702.765
541.130
541.130 189.750
68.310
68.310189.750
541.130
702.765
541.130
541.130 189.750
68.310 937.020
702.765 702.765
702.765
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Department of Pharmaceutical Sciences
937.020
702.765
541.130
541.130 189.750
68.310
68.310189.750
541.130
702.765
541.130
541.130 189.750
68.310 937.020
702.765 702.765
702.765
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Department of Pharmaceutical Sciences
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Department of Pharmaceutical Sciences
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Department of Pharmaceutical Sciences
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Department of Pharmaceutical Sciences
Apotheker
=
Geneesmiddelen informatie specialist
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Department of Pharmaceutical Sciences
Initiation phase
Goal:
Estimate incidence of:
primary defaulting;
filling only one prescription
Identification of patient characteristics
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Department of Pharmaceutical Sciences
Initiation phase
965 patients with a first prescription for a treatment with an antidepressant:
4.2% (42) do not pick up the antidepressant
23.7% (229) picks up only 1 prescription
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Department of Pharmaceutical Sciences
Characteristics of non-starters
OR* 95% CI
Non-specific indication 2.67 1.82-3.91
Niet-western immigrants 4.80 2.05-11.3
>60 years of age 1.81 1.18-2.78
Precollege education level 1.40 0.83-2.36
Poor/moderate self-rated health 1.11 0.76-1.63
Paroxetine 0.78 0.53-1.13
Van Geffen et al Br J Gen Pract (feb 2009)
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Reasons for not starting therapy
57 patients with a single prescription
17 non-starters (29,8%)
Fear of side effects (8)
Aversion towards medication use (3)
Pregnancy (2)
Feeling better (2)
Fear of addiction (1)
Practical reasons (1)
40 (70,2%) stopped within 14 days
Side effect (25)
Aversion towards medication use (7)
Feeling better (6)
Medication ineffective (1)
disagree with diagnosis (1)Ann Pharmacother 2008; 42:218-25
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Department of Pharmaceutical Sciences
“al dat gepraat.. Geef mij maar een pil”
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Department of Pharmaceutical Sciences
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Department of Pharmaceutical Sciences
Patient A (female, 34, paroxetine 1dd)
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Department of Pharmaceutical Sciences
Patient B (male, 41, paroxetine 1dd)
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Department of Pharmaceutical Sciences
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Department of Pharmaceutical Sciences
• 46 stage apotheken gevraagd
• 37 deelnemers
• September – December 2008
• 12-15 antidepressivagebruikers per apotheek
• 46.2% response (245/530)
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Department of Pharmaceutical Sciences
Female gender129 (62.9)
Age 18-30 years 25 (12.2)
31-45 years 61 (29.8)
45-60 years 87 (42.4)
>60 years 32 (15.6)
EducationLow 57 (27.8)
Middle 83 (40.5)
High 60 (29.3)
Having a partner 118 (57.6)
Employment or in school 105 (51.2)
Living with others 141 (68.8)
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Department of Pharmaceutical Sciences
Type of antidepressant Paroxetine 88 (42.9)
Citalopram 48 (23.4)
Fluoxetine 24 (11.7)
Other 45 (22.0)
Reason for use Depression 154 (75.1)
Anxiety 100 (48.8)
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Department of Pharmaceutical Sciences
• 71% gat in de medicatiehistorie
•27% overlap
•2% precies op tijd
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Department of Pharmaceutical Sciences
MARS
•Ik vergeet mijn medicijnen in te nemen
•Ik verander de dosis
•Ik stop tijdelijk
•Ik sla een dosis over
•Ik gebruik minder dan voorgeschreven
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Department of Pharmaceutical Sciences
Adherent (MARS)
All patients (n=205) 153 (74.6)
Gap days
Any (n=147) 107 (72.8)
<5% of OTT (n=40) 38 (95.0)*
5%-19.9% of OTT (n=45) 36 (80.0)*
≥20% of OTT (n=62) 33 (53.2)
Overlapping days
Any (n=53) 41 (77.4)
<5% of OTT (n=20) 18 (90.0)
5%-19.9% of OTT (n=18) 13 (72.2)
≥20% of OTT (n=15) 10 (66.7)
No overlap or gap days (n=5) 5 (100.0)
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Department of Pharmaceutical Sciences
Meldt u dat uw geneesmiddelen anders gebruikt?
Geen gaten
Aan arts: 65%
Aan apotheker: 40%
Wel gaten
Aan arts: 40%
Aan apotheker: 19%
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Department of Pharmaceutical Sciences
Stopping 21% (14) stop abruptly
42% (28) stop with a homemade tapering scheme
30% (20) use a tapering scheme from the GP
6% (4) use a tapering scheme from psychiatrist
Eur J Clin Pharmacol 2005; 61:303-307
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Department of Pharmaceutical Sciences
Discontinuation symptoms
patients DESS-events Gem. (SEM)
P-value
Overall 66 7.2 (0,9)
stopping
tapering 52 5.9 (0.9) 0.006
Abrupt 14 12.0 (2.6)
Eur J Clin Pharmacol 2005; 61:303-307
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Department of Pharmaceutical Sciences
Who fills the need?
pharmacist doctor patient
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Department of Pharmaceutical Sciences
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Department of Pharmaceutical Sciences
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Department of Pharmaceutical Sciences
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