For the treatment of major depressive disorder (MDD), which affects more than 17 million people in the United States, there are multiple prescription therapies that are used to treat depressive symptoms. Consistent with published guidelines, physicians most commonly prescribe a selective serotonin reuptake inhibitor (SSRI) or a serotonin/norepinephrine reuptake inhibitor (SNRI) as first-line treatment. Nevertheless, treatment selection is highly individualized. Therapies such as bupropion (various brands and generics), mixed serotonin modulators, and atypical antipsychotics are also widely used—particularly once an MDD patient fails two or three lines of therapy of adequate dose and duration—both as monotherapy and as part of a combination regimen. Using patient-level claims data, this report explores the position of the leading maintenance therapies in the treatment of MDD and assesses the impact of recent events in the MDD market on treatment patterns, most notably the entrance of generic versions of Eli Lilly’s SNRI Cymbalta (duloxetine)—an event that is increasing the already extensive generics presence in the MDD market—and the launch of two new antidepressants in the United States (Allergan/Pierre Fabre’s Fetzima [levomilnacipran] and Lundbeck/Takeda’s Brintellix [vortioxetine]). The report provides a quantitative analysis of treatment patterns and share by line of therapy among newly diagnosed MDD patients, as well as progression between lines, duration of treatment on each line, and use of concomitant treatment. Among recently treated MDD patients, the report quantifies a drug’s source of business 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 product.

Questions Answered in This Report:

  • Newly diagnosed patients: Not surprisingly, our analysis finds that, in the first year following diagnosis, SSRIs capture the greatest first-line patient share among drug classes included in our analysis; nearly two-thirds of MDD patients are treated with SSRIs first-line, in particular sertraline (Pfizer’s Zoloft, generics) and escitalopram (Allergan’s Lexapro, generics). What brands garner the greatest first-line patient share in newly diagnosed MDD patients? To what extent has generic duloxetine penetrated early lines of therapy? What are the dynamics of branded agents, such as Seroquel XR (AstraZeneca), Abilify (Bristol-Myers Squibb/Otsuka), Fetzima (Allergan/Pierre Fabre), and Brintellix (Lundbeck/Takeda) across second and third lines of therapy?

  • Recently treated patients: Consistent with historical treatment patterns, the SSRI drug class continues to capture the majority of recently treated MDD patient prescriptions. Which specific SSRI garners the most patient share among recently treated MDD patients? What patient shares do other key therapies across all drug classes under study—including duloxetine—capture in recently treated patients? Which drug(s) precede the use of Fetzima and Brintellix, the more recently launched antidepressants in the United States? In a market characterized by high “churn,” which drugs have the best persistency and compliance rates? Are most patients recently treated with each key therapy coming from new (adds/switches) or continuing business?

  • 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?


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. The report is delivered as a key findings slide deck and a dashboard that can be accessed using the Internet with claims that are 6-12 months old at the time of publication.

Patient Sample: Patients aged 15 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 drug class and 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 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.

- Quarterly trends in patient share for all key therapies.

Author(s): Bethany A. Kiernan, Ph.D.
Angela M. Sparrow, Ph.D.

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