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Remission and residual symptomatology in major Disord 2001;65:27–36 purchase casodex 50mg overnight delivery. Three-year outcomes for 1092 Neuropsychopharmacology: The Fifth Generation of Progress maintenance therapies in recurrent depression buy 50 mg casodex free shipping. Five-year outcome for drome/premenstrual dysphoric disorder: a randomized con- maintenance therapies in recurrent depression discount 50 mg casodex with visa. Nortiptyline and faxine extended-release capsules in nondepressed outpatients interpersonal psychotherapy as maintenance therapies of recur- with generalized anxiety disorder: a 6-month randomized con- rent major depression: a randomized, controlled trial in patients trolled trial. Columbia atypical release venlafaxine in nondepressed outpatients with generalized depression. A subgroup of depressives with better response to anxiety disorder. J Clin Psychopharmacol 1998;18: specificity in atypical depression. Depression, delusions, sertraline treatment of posttraumatic stress disorder: a random- and drug response. Am J Psychiatry 1985;142: investigation of fixed-dose fluoxetine in the treatment of ob- 430–436. Sertraline in the treatment of obsessive compul- of psychotic depression. Amoxapine versus amitriptyline Clin Psychopharmacol 1992;7(Suppl 2):37–41. Methods to improve pramine, and cognitive therapy in the treatment of panic disor- diagnostic accuracy in a community mental health setting. J Psychopharmacol (Oxford) 2000; Washington, DC: Superintendent of Documents, US Govern- 14(Suppl 1):S25–S30. A new depression scale designed J Affect Disord 2001;64:81–87. J Neurol Neurosurg and insomnia influence antidepressant selection: a randomized Psychiatry 1960;23:56–62. Development of a rating scale for primary depres- 1998;59:49–55. Reboxetine is effective and well tolerated in the 56. The inventory for depressive symptomatology (IDS): preliminary findings. Reboxetine: additional benefits to the de- pressive Symptomatology (IDS): psychometric properties. J Psychopharmacol (Oxford) 1997;11(Suppl 4): chol Med 1996;26:477–486. Psychopharmacology: fourth generation of cacy and tolerability of the selective norepinephrine reuptake progress. Toward a rational pharmacother- 1997;58(Suppl 13):23–29. Are patients who are intolerant to tine, bupropion, and placebo in the treatment of premenstrual one serotonin selective reuptake inhibitor intolerant to another? Response to an open ment for premenstrual dysphoric disorder. J Clin Psychopharma- trial of a second SSRI in major depression. Does intolerance or provement of premenstrual dysphoric disorder with sertraline lack of response with fluoxetine predict the same will happen treatment. Fluoxetine treat- Chapter 75: Current and Emerging Therapeutics for Depression 1093 ment of patients with major depressive disorder who failed ini- an adequate antidepressant trial for fluoxetine? Modern problems to fluoxetine as a predictor of poor 8-week outcome. What to do with SSRI nonrespond- psychotherapy of depression. Venlafaxine for response to acute treatment in recurrent depression. Efficacy of venlafaxine life depression: analysis of effects of demographic, treatment, in depressed patients after switching from prior SSRI treatment. Bupropion treat- ity of mirtazapine versus citalopram: a double-blind, random- ment of fluoxetine-resistant chronic fatigue syndrome. Biol Psy- ized study in patients with major depressive disorder. Rapid onset of therapeutic etine-associated sexual dysfunction in patients switched to bu- action in major depression: A comparative trial of mirtazapine propion. Nefazodone treat- American College of Neuropsychopharmacology, Las Croabas, ment of patients with poor response to SSRIs. Mirtaza- pharmacology, San Juan, Puerto Rico, December 1998. Nefazodone versus patients with moderate to severe major depressive disorder. J sertraline in outpatients with major depression: focus on effi- Clin Psychiatry 1998;59:306–312. Double-blind crossover study of Clin Therapeut 1998;20:517–526. American Psychiatric Association, New York, NY, May 1996. Presented at the 152nd Annual Report/Technology Assessment, Number 7. Treatment of Meeting of the American Psychiatric Association, Washington, depression: newer pharmacotherapies. Switching fluoxetine to Care Policy and Research, AHCPR Publication 99-E014, 1999.

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Biol Psychiatry 1999;45: cingulate gyrus in major depression order casodex 50mg amex. Quantitation of nin type 2A receptors in late-life neuropsychiatric disorders cheap casodex 50 mg on line. In the last decade or so purchase casodex 50mg without prescription, several new antidepressants have higher acquisition costs when more than one pill is required been introduced into practice, including the selective seroto- for a particular dose. Regardless of these caveats, it is clear nin reuptake inhibitors fluoxetine (1987), sertraline (1991), that the newer generation of antidepressants is more expen- paroxetine (1992), and citalopram(1998), in addition to sive to purchase than are the older generations. Two of these medications are avail- determine whether these new, more expensive medications able in delayed-release formulations: bupropion SR (1996) are cost-effective as first-line treatment in comparison with and venlafaxine XR (1997). Only one of these medications the older, less expensive antidepressants. In other words, in is currently available in a generic formulation (bupropion, lay terms, are the newer medications worth the prices 1999). Despite their higher acquisition costs, the newer Each of these medications is more expensive in terms of antidepressants could be more cost-effective if they resulted acquisition costs than the older generation of tricyclics and in greater increases in quality of life and functioning, or in heterocyclics and monoamine oxidase inhibitors. Together, a reduction of the nonmedication costs of illness in compari- the newer generations of antidepressants accounted for ap- son with the older antidepressants sufficient to offset their proximately $7. The World Health Organization has Drug Topics 'Red Book' (2). Actual costs to health care calculated that depression was the fourth leading cause of systems or patients can be substantially lower or higher than disease burden throughout the world in 1990, and projected the figures in Table 78. Certain health care systems are able to costs of depression to society as a result of productivity lost qualify for discounted prices for certain medications, and because of morbidity and mortality have been estimated at patients can sometimes receive medications free of charge $14. Moreover, direct treatment costs for costs are also lowered by patient noncompliance. In addi- depression, exclusive of medication acquisition costs, have tion, some of the newer antidepressants are available as been estimated at $2. Most of these costs doses have the opportunity to reduce costs substantially with were related to hospitalization. The better tolerability of the only the modest inconvenience entailed by breaking the newer versus the older antidepressants might well lead to pills. However, higher doses of some medications lead to reductions in these expensive treatment services. A formal determination of whether the higher acquisi- tion price of the newer antidepressants relative to the older Scott W. Bruce Baker: Department of Psychiatry, Yale antidepressants is offset by savings in other areas or increased University School of Medicine, New Haven, Connecticut. AVERAGE WHOLESALE PRICE FOR A 30-DAY SUPPLY OF NEWER ANTIDEPRESSANTS Average Wholesale Price ($)a Strength Antidepressant (mg) Dosing Brand Generic Fluoxetine 10b QD 76. For QD dosing, the lowest cost for 30 pills was used, and 60 pills for BID dosing and 90 pills for TID dosing. When few or no suppliers offered lots of 30, 60, or 90 pills, the lowest-price 100-pill lot was multiplied by 0. Cost-effectiveness is represented as a ratio between sumed in providing the intervention, in this case the treat- direct costs, the numerator, and changes in health status, ment of depression, which includes dealing with side effects the denominator. The relative cost-effectiveness of newer and other consequences. Direct costs are further subdivided versus older antidepressants is represented as the incremen- into four major categories. The first category encompasses tal or marginal difference between the cost-effectiveness ra- changes in the use of health care resources (e. The sec- effectiveness of switching to secondary treatments, postu- ond category of direct costs encompasses changes in the use lated lengths of treatment, and costs and health effects in- of other resources (e. Direct costs are the resources con- Health effects are divided into two major categories. In Chapter 78: Cost-effectiveness of the Newer Antidepressants 1121 the first category, the intrinsic value of changes in health Some of the perspectives commonly discussed or used status, a value is placed on achieving or avoiding a specific include the following: patient or patient/family, employer/ health state. The health state may be characterized by using a payer, individual health care institution (e. The outcomes mea- health), national health care comprehensive system (i. In practice, when intermediate out- In considering whether the available studies suggest that comes are used, the health state and cost-effectiveness ratio newer antidepressants are cost-effective, we will limit our- is sometimes denoted simply in the native units of a single selves to addressing the question fromthe two perspectives domain (e. First, we ask, 'Are newer and value weights are not assigned. In fuller analyses, antidepressants cost-effective as first-line treatment from a weights are assigned to the benefits, and the weights are health care systemperspective? The most com- ate that the studies to be reviewed have utilized multiple mon generic unit is the quality-adjusted life year (QALY). Some studies im- The second category major category of health effects, plicitly or explicitly assume equal effectiveness of newer and indirect costs or productivity effects, refers to resource con- older antidepressants and ask whether the first-line use of sumption attributable to changes in productivity caused by newer antidepressants produces savings to the health care changes in morbidity or mortality. Others model or measure clinical benefit and sectors of health care, even if the specific intervention falls calculate average or incremental cost-effectiveness ratios. In more limited analyses, tions in design and methods. Most of the evidence regarding the categories are applied only in the specialty sector. The Second, we ask, 'Are newer antidepressants cost-effective many types of prices that can be assigned to resources, and as first-line treatment from a global societal perspective? The conclusions suggested by any given cost-effective- We also examine studies reporting relative rates of cost- ness analysis depend heavily on each of the factors we have effectiveness of the newer antidepressants. The conclusions of the analysis also depend on its particularly on the newer antidepressants and updating our perspective—that is, for whomis the treatment cost-effec- previous review (7). The perspective determines which costs, benefits, and by a search of Medline, Current Contents, and outcomes are potentially relevant and what weights are ap- HealthSTAR computer databases and by manual biblio- propriate. Clarity about perspective is critical because in graphic review.

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With a greater understanding of the scope of universal health coverage buy casodex 50mg otc, many national governments now view progress towards that goal as a guiding principle for the development of health systems 50 mg casodex fast delivery, and for human development generally discount casodex 50mg line. It is clear that healthier environments mean healthier people (9). Preventive and curative services protect health and protect incomes (10, 11). Healthy children are better able to learn, and healthy adults are better able to contribute socially and economically. Te path to universal health coverage has been dubbed “the third global health transition”, afer the demographic and epidemiological transitions (12). Universal coverage is now an ambition for all nations at all stages of develop- ment. Te timetable and priorities for action clearly difer between countries, but the higher aim of ensuring that all people can use the health services they need without risk of fnancial hardship is the same everywhere. The Alma Ata Declaration is best known for promoting primary health care as a means to address the main health problems in communities, fostering equitable access to promotive, preventive, curative, palliative and rehabilitative health services. The idea that everyone should have access to the health services they need underpinned a resolution of the 2005 World Health Assembly, which urged Member States “to plan the transition to universal coverage of their citizens so as to contribute to meeting the needs of the population for health care and improving its quality, to reducing poverty, and to attaining internationally agreed development goals” (3). The central role of primary care within health systems was reiterated in The world health report 2008 which was devoted to that topic (4). The world health report 2010 on health systems financing built on this heritage by proposing that health financing systems – which countries of all income levels constantly seek to modify and adapt – should be developed with the specific goal of universal health coverage in mind. The twin goals of ensuring access to health services, plus financial risk protection, were reaffirmed in 2012 by a resolution of the United Nations General Assembly which promotes universal health coverage, including social protection and sustainable financing (5). The 2012 resolution goes even further; it highlights the importance of universal health coverage in reaching the MDGs, in alleviating poverty and in achieving sustainable development (6). It recognizes, as did the “Health for All” movement and the Alma Ata Declaration, that health depends not only on having access to medical services and a means of paying for these services, but also on understanding the links between social factors, the environment, natural disasters and health. The world health report 2013: research for universal health coverage addresses questions about prevention and treatment, about how services can be paid for by individuals and govern- ments, about their impact on the health of populations and the health of individuals, and about how to improve health through interventions both within and beyond the health sector. Although the focus of universal health cover- age is on interventions whose primary objective is to improve health, interventions in other sectors – agriculture, education, finance, industry, housing and others – may bring substantial health benefits. Developing the concept of and palliative care, and these services must be sufcient to meet health needs, both in quantity universal health coverage and in quality. Services must also be prepared for Te world health report 2010 represented the the unexpected – environmental disasters, chem- concept of universal health coverage in three ical or nuclear accidents, pandemics, and so on. Measuring progress towards ating whether interventions are effective and universal health coverage in three affordable. When people on low incomes with no fnancial risk protection fall ill they face a dilemma: if a local health service Include Reduce cost-sharing other exists, they can decide to use the service and and fees services sufer further impoverishment in paying for it, or they can decide not to use the service, remain ill and risk being unable to work (20). Te general Extend to Current pooled solution for achieving wide coverage of fnancial non-covered funds Services: risk protection is through various forms of pre- which services payment for services. Tis spreads the fnancial risks of ill-health across of afordability – usually set at zero for the poor- whole populations. Prepayment can be derived est and most disadvantaged people. Te total from taxation, other government charges or volume of the large box in Fig. Te volume of the smaller blue box Financial risk protection of this kind is an shows the health services and costs that are cov- instrument of social protection applied to health ered from pre-paid, pooled funds. It works alongside other mechanisms of universal coverage is for everyone to obtain the social protection – unemployment and sickness services they need at a cost that is afordable to benefts, pensions, child support, housing assis- themselves and to the nation as a whole. The countries, cannot usually raise sufficient funds services that are needed differ from one setting by prepayment to eliminate excess out-of- to another because the causes of ill-health also pocket expenditures for all the health services vary. The balance of services inevitably changes that people need (1). It is therefore a challenge over time, as new technologies and procedures to decide how best to support health within emerge as a result of research and innovation, budgetary limits. How Thailand assesses the costs and benefts of health interventions and technologies In 2001 the Government of Thailand introduced universal health coverage fnanced from general taxation. Economic recession underlined the need for rigorous evaluation of health technologies that would be eligible for funding in order to prevent costs from escalating. At the time, no organization had the capacity to carry out the volume of health technology assessments (HTAs) demanded by the government. Therefore the Health Intervention and Technology Assessment Programme (HITAP, www. Unlike the National Institute for Health and Clinical Excellence (NICE) in England and Wales, which evaluates existing interventions only, HITAP does primary research, including observational studies and randomized controlled trials, as well as systematic reviews and meta-analyses based on secondary literature analysis. Its output takes the form of formal presentations, discussion with technical and policy forums and academic publications. Despite the intro- duction of Papanicolaou (Pap) screening at every hospital over 40 years ago, only 5% of women were screened. Visual inspection of the cervix with the naked eye after application with acetic acid (VIA) was introduced as an alternative in 2001 because it did not require cytologists. The options considered by HITAP were conventional Pap screening, VIA, vaccination or a combination of Pap screening and VIA. Costs were calculated on the basis of estimated levels of participation and included costs to the health-care provider, costs for women attending screening and costs for those who were treated for cervical cancer. Potential benefts were analysed by using a model that estimated the number of women who would go on to develop cervical cancer in each scenario, and the impact on quality-adjusted life years (QALYs) was calculated by using data from a cohort of Thai patients. The study concluded that the most cost-efective strategy was to ofer VIA to women every fve years between the ages of 30 and 45, followed by a Pap smear every fve years for women aged between 50 and 60 years. Universal introduction of vaccination for 15-year-old girls without screening would result in a gain of 0. The approach recommended by HITAP was piloted in several provinces starting in 2009, and this has now been imple- mented nationally. HITAP attributes its success to several factors: ■ the strong research environment in Thailand which, for instance, provides staff for HITAP and supports peer review of their recommendations; ■ collegiate relationships with similar institutions in other countries, such as NICE in England and Wales; ■ working with peers (HITAP meets with other Asian HTA institutions, and has formed an association with Japan, Malaysia and the Republic of Korea); ■ transparency in research methods, so that difficult or unpopular decisions can be understood; ■ a code of conduct (HITAP adheres to a strict code of behaviour which, for instance, precludes acceptance of gifts or money from pharmaceutical companies); ■ political support from government, fostered by opening doors to, and discussing methods with, decision-makers; ■ popular support, generated by lectures at universities and dissemination of recommendations to the general public; ■ external review (HITAP commissioned an external review of its methods and work in 2009). A representation of the results chain for universal health coverage, focusing on the outcomes Inputs and processes Outputs Outcomes Impact Health nancing Service access and Coverage of Improved health status Health workforce readiness, including interventions Improved nancial medicines well-being Medicines, health products Financial risk and infrastructure Service quality and safety Increased responsiveness protection Information Service utilization Increased health security Risk factor mitigation Governance and legislation Financial resources pooled Crisis readiness Quantity, quality and equity of services Social determinants Note: Each of these outcomes depends on inputs, processes and outputs (to the left), and eventually makes an impact on health (to the right).

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