For the first-line treatment of major depressive disorder (MDD), physicians most commonly prescribe a selective serotonin reuptake inhibitor (SSRI), serotonin/norepinephrine reuptake inhibitor (SNRI), or bupropion (various brands and generics) within one year of a patient’s diagnosis. Most of the drugs in these classes are currently available as low-priced generics; Eli Lilly’s Cymbalta became generically available in early December 2013. Our quantitative analysis of patient-level claims data indicates that the patient shares of more recently launched antidepressants including Actavis’s (formerly Forest Laboratories’) Viibryd (vilazodone) among newly diagnosed MDD patients continue to be 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). Very recently-launched agents for MDD, which include Lundbeck/Takeda’s Brintellix (vortioxetine) and Actavis/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. This report uses national patient-level claims data to explore the position of the leading maintenance therapies in the treatment of newly diagnosed MDD patients with a quantitative analysis of treatment patterns and share by line of therapy, as well as progression between lines, duration of treatment on each line, and use of concomitant treatment. The report also quantifies a drug’s source of business among recently treated MDD patients compared with its competitors and details which drugs precede others through an analysis of add-versus-switch patterns. Additional analyses explore persistency and compliance by brand.

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 (Actavis’s Celexa, generics), sertraline (Pfizer’s Zoloft, generics), and escitalopram (Actavis’s Lexapro, generics). What drugs and drug classes compete for first-line patient share in newly diagnosed MDD patients? What are the dynamics of branded agents such as Seroquel XR (AstraZeneca) and Abilify across second and third lines of therapy?

  • Recently treated patients: Cymbalta had previously dominated patient share among SNRIs in our analysis of recently treated MDD patients, and generic duloxetine became available during the last month of our study period (December 2013). Cymbalta is favored among members of its class for treating patients with MDD and comorbid pain conditions. What was the share of generic duloxetine in recently treated MDD patients three weeks after its launch, and what was the impact on Cymbalta’s patient share? How much of its use was preceded by Cymbalta? What percentage of recently treated patients taking generic duloxetine were switched from Cymbalta?

  • 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 and bupropion? Which drug(s) precede the use of Viibryd, one of the more recently launched antidepressants in the United States?

Scope:

Primary patient-level data: This report provides quantitative findings from our analysis of data covering approximately 40 million lives and provides 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, 296.3) during the study period.

Quantified lines of therapy analyses show 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 key products across three lines of therapy, within one year of diagnosis.

- Patient flowcharts 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 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.