Study Objectives: There is renewed interest in the use of MAOIs for the treatment of MDD, specifically MDD with atypical features, anxious features, and treatment-resistant depression (TRD). The American Psychiatric Association and the British Association for Psychopharmacology guidelines for depression list use of MAOIs as an option for TRD. Selegiline is an irreversible inhibitor of MAO enzymes. The selegiline transdermal system (STS) bypasses first-pass metabolism, and thereby inhibits MAO in the brain without significantly inhibiting MAO in the gut. The present study was designed to discern: (i) the pattern (sequence) of use of STS in MDD; (ii) level of adherence to STS as compared to alternative antidepressant pharmacotherapy regimens; and (iii) the effect on health service expenditures. Method: This research employed patient-level data abstracted from domestic (U.S.) longitudinal archives (Medicaid; Medicare; managed care), cross-sectional surveys (U.S. National Center for Health Statistics), and the published literature. MDD was defined as ICD-9-CM codes 296.2, 296.3, 300.4 or 311. Treatment failure (TF) was defined as receipt of <90 days of initial antidepressant pharmacotherapy. For longitudinal analyses primary criterion were: (1) ambulatory patients aged 18 through 75 years; (2) continuous enrollment of 18 months (six months prior to an ICD-9-CM code for MDD (index date); 12 months post index date); (3) no ICD-9-CM code(s) for co-morbid mental illness; (4) initial antidepressant pharmacotherapy: SSRI, SNRI, or STS. Multivariate logistic regression and log-transformed multivariate linear regression were used to assess sequential use of antidepressant pharmacotherapy, level of adherence, and health service expenditures (intent-to-treat [ITT] and propensity-score basis), respectively. Results: For the majority of patients, STS was prescribed as a second or third treatment option for MDD. Specifically, post TF with one SSRI or SNRI (22%); post TF with a second SSRI or SNRI (67%); or post TF with an SSRI or SNRI and augmentation with an atypical antipsychotic (11%). STS was associated with a greater probability of receipt of 60, 90, or 180 days of pharmacotherapy (p<0.05). Use of STS resulted in reduced (p<0.05) or comparable (p=NS) health services expenditures dependent on the use pattern sequence post the index date. Conclusions: Treatment failure is associated with increased health service expenditures. Use of STS post TF (ITT or propensity-score basis) resulted in increased adherence and comparable or reduced health service expenditures. After an antidepressant TF, early use of STS may be warranted. Educational Objective: After studying this material, participants should be better able to understand patterns of use and in healthcare expenditures with a transdermal MAOI in patients with MDD. Funding: This study was supported by funding from Mylan Specialty L.P.
Lawrence Cohen, PharmD, BCPP, FASHP, FCCP, FCP; David Sclar, B.Pharm, PhD; Kimberly Portland, PhD
Mylan Specialty L.P.