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Research & Reports

Searching in Biopharma (1575)

Key Findings from Treatment Algorithms: Major Depressive Disorder

For the first-line treatment of major depressive disorder (MDD), physicians most commonly prescribe a selective serotonin reuptake inhibitor (SSRI) or serotonin/norepinephrine reuptake inhibitor (SNRI) within one year of rendering a diagnosis. Most of the drugs in these classes are currently available as low-priced generics. Our quantitative analysis of patient-level claims data indicates that the patient shares of more recently launched antidepressants, including Forest Laboratories’ Viibryd (vilazodone), among newly diagnosed MDD patients are much lower than those of generic products in first- and even second-line therapy—demonstrating the increasing difficulty that new products are having penetrating the MDD market. As a result of this environment, marketers of MDD products have turned their attention to those patients who fail to respond adequately to first-line SSRIs and SNRIs. This patient population is substantial: More than 40% of newly diagnosed MDD patients move to a second-line therapy within the first year of diagnosis, according to our analysis, and more than one-half of these patients move to a third-line therapy in the first year, a trend that is consistent with the fact that patients are less likely to respond to a subsequent drug after each failed treatment attempt. These data highlight the market potential for therapies approved to treat MDD patients with an inadequate response to SSRIs and/or SNRIs, such as Bristol-Myers Squibb/Otsuka’s atypical antipsychotic Abilify (aripiprazole) and AstraZeneca’s Seroquel XR (quetiapine XR). Emerging agents for MDD, which include Lundbeck/Takeda’s Brintellix (vortioxetine) and Forest Laboratories/Pierre Fabre’s Fetzima (levomilnacipran), will also compete for second-line share in patients who fail first-line SSRI/SNRI use, despite the lack of specific regulatory approval for this patient population.

Using patient-level claims data, this report tracks the share of antidepressant drugs through lines of therapy, evaluates treatment flow, and analyzes why certain key therapies are chosen over others in light of the multiple antidepressant therapies available.

Questions Answered in This Report:

  • Newly diagnosed patients: Not surprisingly, our analysis finds that, in the first year of diagnosis, more than half of MDD patients are treated with SSRIs first line; the SSRIs capturing the greatest first-line patient share among newly diagnosed patients are citalopram (Forest’s Celexa, generics), sertraline (Pfizer’s Zoloft, generics), and escitalopram (Forest’s Lexapro, generics). Which products capture the most patient share in second- and third-line MDD treatment, and to what extent are these agents used as part of combination treatment? What proportion of newly diagnosed MDD patients receives an atypical antipsychotic as a second- and third-line therapy after trying SSRIs? Of these atypical antipsychotics, which capture the most patient share in second and third lines?

  • Recently treated patients: Bupropion has historically been the most common adjunctive therapy to SSRIs and SNRIs in MDD patients failing to respond to first-line monotherapy. Abilify and Seroquel XR are also used as adjunctive therapies as a result of these products’ FDA approval for this indication, as is quetiapine (AstraZeneca’s Seroquel, generics). How common is it that bupropion precedes treatment with Abilify or Seroquel XR in MDD? From which drugs do Abilify and Seroquel XR derive the majority of their business, and what does it say about how these products are being used in treatment-resistant MDD? How long does it take a patient to progress to treatment with Abilify or Seroquel XR, and how do the pathways to each product differ?

  • Pathways to key therapies: Longitudinal claims data reveal that bupropion is the leading agent among recently treated MDD patients; these data also detail which agents in a given class compete with bupropion. Which drugs precede the use of bupropion? When bupropion is prescribed as part of a combination regimen, which drugs are used most often in combination with bupropion? To what extent is Abilify competing with immediate-release quetiapine? Which drug(s) precede the use of Viibryd, one of the most recently launched antidepressants in the United States?


Primary patient-level data: Quantitative findings from our analysis of data covering approximately 40 million lives providing the most representative sample of U.S. treatment practice for Medicare and commercially insured patients. This report is delivered as a key findings slide deck and a dashboard that can be accessed using the Internet with claims that are less than six months old at the time of publication.

Patient Sample:

- Patients aged 18 or older who are continuously enrolled for the complete two-year study period must meet the following condition: at least one claim with a diagnosis code for MDD (International Classification of Diseases, Ninth Revision [ICD-9] diagnostic codes (296.2 and 296.3) during the study period.

- Quantified lines of therapy analysis showing exact share of each agent in each line of therapy, including rate of progression between lines and length of time patients are on each line.

Newly Diagnosed Patients:

- Patient share by drug class and key products across three lines of therapy, within one year of diagnosis.

- Patient flowchart through one year of treatment for all first-line products, including progression rates and add/switch behavior.

- Polypharmacy and key concomitant therapies by line of therapy.

- Quarterly trending of patient share by line of therapy.

Recently Treated Patients:

- Quarterly snapshot of patient share by drug class and key products.

- Pathway to key therapy flowcharts tracking the preceding therapy patterns for all key therapies, including add/switch behavior.

- Brand source of business including share for continuing, new (switches/adds), and new (initial therapy) business.

- Polypharmacy and key concomitant therapies.

- Drug persistence and compliance.

- Quarterly trending of patient share for all key therapies.