Assessment
of Prescribed Class of Anxiolytics and Antidepressants- In Terms of Efficacy,
Quality of Life and Cost Analysis In a Tertiary Care Hospital
Kingston R1*, Shivakumar Swamy2 and
Arihara Sivakumar1
1 KMCH college of Pharmacy, Dep. of Pharmacy Practice, Coimbtore,
Tamil Nadu-641014, India
2Mallige College of Pharmacy,
Bangalore-5620090.
ABSTRACT
Though the non-pharmacological treatment
play a key role in anxious and depressive patients the drugs like
antidepressants and anxiolytics have an elegant role in treating these
patients. The success rates with newly diagnosed patients were better. Drugs
are necessary to reduce the risk of developing chronic conditions. We have
assessed the efficacy of anxiolytics and antidepressants prescribed (to newly
diagnosed patients), cost of medications, quality of life in a Multi Specialty
Hospital. An assessment was made in newly diagnosed patients with anxiety and
depression to study the efficacy of antidepressants and anxiolytics prescribed
to them, and their quality of life. Also, the total cost incurred by the
patients for one month after diagnoses were evaluated. 100 patients were
included in this study, conducted over a period of 6 months. The study sample
consisted of 61 females and 39 males. Patients were treated with both single
and two drug therapy. There was a significant difference in both the therapy.
With the mean differences in both the therapy groups, single drug therapy
itself is effective for treating the newly diagnosed patients. All the drugs
prescribed significantly improved the health condition of anxiety and
depressive patients. In single drug therapy Escitalopram is considered as the
drug that has more efficacies with respect to the mean values. Same way in two
drug therapy the combination of Escitalopram+Alprazolam is more effective with
respect to the mean values. Regarding the cost analysis, Escitalopram is the
costliest drug. Though the quality of life of the patients shows significant
improvement, it can be improved much more through patient awareness programs
and patient education.
INTRODUCTION
Psychiatric illnesses are fundamentally no
different from mental illness. Historically illness in which there was a
prominent disturbance of psychological function or behaviors and no obvious pathology came
to be regarded as psychiatric. We know
that there is demonstratably altered brain function in many psychiatric
disorders and the psychological disturbances are common in medical illness.
Hence regarding psychiatric illness as mental as opposed to physical is
incorrect. Psychiatric illness is no less real or less deserving of care than
medical conditions.
Diagnosis in psychiatry, as much of medicine
is based mainly on identifying recognized patterns of subjective symptoms. These symptoms involve
abnormalities of behavior, mood, perceptions, thinking and intellectual functions.
Many psychiatric ill patients are
socially isolated and this often appears to be contributory factor in their
illness.1 Recent epidemiological studies have provided data on the
number of people with mental and
addictive disorders. Many of these people receive their care in the general
medical care sector. This has important implications for diagnosis and
treatment of mental and addictive disorders2.
Table: 1 AGE DISTRIBUTION
AMONG THE STUDY GROUP
|
AGE IN YEARS |
NUMBER OF PATIENTS |
PERCENTAGE |
|
<20 |
2 |
2 |
|
21-30 |
12 |
12 |
|
31-40 |
58 |
58 |
|
41-50 |
24 |
24 |
Table: 2 GENDER DISTRIBUTIONS AMONG
THE STUDY GROUP
|
GENDER |
NUMER OF PATIENTS |
PERCENTAGE |
|
MALE |
38 |
38 |
|
FEMALE |
62 |
62 |
Nearly 14% of
the consultations in general
practice are wholly or
largely for psychological
reasons. Anxiety disorders are prevalent
psychiatric illness present in
15 to 20% of the medical clinic patients. 20% of the patients present
with mood, anxiety or substance abuse disorders, the most common being
panic disorders.75% of the patients
with panic disorders are prone
to major depression. Panic disorder is
most prevalent in 43% of
the patients with chest pain.3
A common and serious mental disorder characterized by
loss of contact with reality (psychosis), delusion (false beliefs), abnormal
thinking, flattened affect (restricted range of emotion), and diminished
motivation and disturbed work and social functioning4. The purpose
of this study is to assess the efficacy of anxiolytics and antidepressants
prescribed (to newly diagnosed patients), cost of medications, quality of life
in a Multi Specialty Hospital.
METHOD:
The study was carried out at Kovai Medical Center and
Hospital; Coimbatore Tamil Nadu, India. This is a 500-bedded modernized, multi
specialty tertiary care hospital with
full-fledged Psychiatry Department. It caters to the needs of both out patients
and in patients.
An assessment was made in
newly diagnosed patients with anxiety and depression to study the efficacy of
antidepressants and anxiolytics prescribed to them, and their quality of life.
Also, the total cost incurred by the patients for one month after diagnosis was
evaluated. 100 patients were included in this study, conducted over a period of
6 months between June to November 2006.
Psychiatric rating scales were used to assess the
efficacy and quality of life of the patients. A standard hospital anxiety and
depression scale and internet mental health quality of life questionnaires were
used to evolve the efficacy and quality of life respectively. The scores for
the same were taken initially and after 1-month interval. From the mean values
of these scorings, the efficacy of the drugs was assessed, single and two drugs
therapy separately. Also the total cost incurred for medications by the
patients for one month after diagnosis was also calculated.
Note: Regarding Internet Mental Health Quality of Life
questionnaires, it was modified to assess only the mental health of the
patients such that only the psychological and social states were included in
the modified questionnaires. For this a request was sent to the Director of
Internet Mental Health and it was granted through email.
Table: 3 SOCIAL HABITS AMONG THE STUDY
GROUP
|
SOCIAL HABIT |
NUMER OF PATIENTS |
PERCENTAGE |
|
SMOKERS |
8 |
8 |
|
ALCOHOLICS |
4 |
4 |
|
TOBACCO CHEWERS |
2 |
2 |
|
NIL |
84 |
84 |
Table: 4 OCCUPATIONAL
DISTRIBUTIONS AMONG THE STUDY GROUP
|
OCCUPATION |
NUMBER OF PATIENTS |
PERCENTAGE |
|
BUSINESS |
34 |
34 |
|
HOUSE
WIFE |
58 |
58 |
|
OFFICE
WORKERS |
4 |
4 |
|
STUDETN |
2 |
2 |
|
NIL |
2 |
2 |
Table: 5 DRUG REGIMENS AMONG THE STUDY
GROUP
|
DRUG
REGIMEN |
NUMBER
OF PATIENTS |
PERCENTAGE |
|
SINGLE DRUGS |
52 |
52 |
|
TWO DRUGS |
48 |
48 |
RESULTS:
The age range of patients varied from 18 to 50 years,
2% (N=2) were in the age group < 20, 12% (N=12) were in the age range of
21-30, 58% (N=58) were in the age range of 31-40 and 24% (N=24) were in the age
range of 41-50 years. Most of the patients’ were between 31 to 40 years of age
(see Tab: 1). this result has controversy from the study conducted in
University of Nebraska in the year 1999 which says that youth in the age range
of 18-25 were more affected compared to adult11.Data were collected
from 100 patients, in which 61% (N=61) were female and (39%) (N=39) were male
(See Tab: 2). It was noted that women received more drugs than men. This can be
compared with the results of other study 6,7. According to the marital status, only 1
patient is unmarried and the others are married.
Regarding the social habits, 8%
(N=8) were smokers, 4% (N=4) were alcoholics, 2% (N=2) were using tobacco and
84% (N=84) were not having any habits (See Tab: 3). When the occupation was
recorded, 58% (N=58) were housewives, 34% (N=34) were in business, 4% (N=4)
were office workers, 2% (N=2) were student and 2% (N=2) had no occupation. (See
Tab: 4). However no literature was available for this study, which correlates with
the occupation.Regarding the drug regimens among the study group, 52% (N=52)
were under single drug therapy and 48% (N=48) were under two drugs therapy (See
Tab: 5).
In single drug therapy among the study group,53% (N=28)
were taking Escitalopram and 47% (N=24) were taking Clomipramine (See Tab:
6).In two drugs therapy among the study group, 58% (N=28) were taking
Escitalopram+Alprazolam and 42% (N=20) were taking Clomipramine+ Alprazolam
(See Tab: 6).The dose ranges of the drugs given to the patients were
Escitalopram 5mg b.i.d, Clomipramine 10mg o.d as single drug therapy.
Escitalopram 5mg b.i.d +Alprazolam 0.25mg b.i.d and Clomipramine 10mg o.d +
Alprazolam 0.25 b.i.d as two drug therapy.
Paired t test analysis Hospital
Anxiety and Depression Scale and Internet Mental Health Quality of Life showed
a significant improvement (P=0.001) and for all the drugs in single and
two-drug therapy.
Table: 6 DRUGS USED AMONG THE STUDY
GROUP
|
DRUGS USED |
NUMER OF PATIENTS |
PERCENTAGE |
|
ESCITALOPRAM |
28 |
28 |
|
CLOMIPRAMINE |
24 |
24 |
|
ESCITALOPRAM+ALPRAZOLAM |
28 |
28 |
|
CLOMIPRAMINE+ALPRAZOLAM |
20 |
20 |
|
DRUGS [SINGLE DRUG THERAPY] |
MEAN DIFFERNECE FOR ANXIETY |
||
|
ANXIETY |
DEPRESSION |
QUALITY OF LIFE |
|
|
ESCTALOPRAM |
9.33 |
10.06 |
15.79 |
|
CLOMIPRAMINE |
7.08 |
8.5 |
13.58 |
Table:
7. MEAN DIFFERENCES FOR ANXIETY, DEPRESSION, QUALITY OF LIFE AMONG THE STUDY
GROUP [SINGLE DRUG THERAPY]
Assessment for Anxiety, Depression and Quality of life
Scale were taken separately. The scorings for Hospital Anxiety and Depression
Scale and Internet Mental Health Quality of Life shows significant positive
difference from initial to review values. The pre and post treatment mean
values of Escitalopram group for anxiety are 11.9 (±2.37SD) and 2.57 (±1.02SD),
for depression 12.2 (±2.67SD) and 2.14 (±1.30SD) and quality of life are 18.0
(±2.66SD) and 2.21 (±1.19SD) , hence mean difference of them are 9.33, 10.06,
15.79 respectively. Where as the pre and
post treatment mean values in Clomipramine group, for anxiety are 10.0 (±3.02SD)
and 2.92 (±1.16SD), depression are11.0 (±1.21SD) and 2.50 (±1.09SD), quality of
life are 16.5 (±2.94SD) and 2.92 (±1.98SD), accordingly mean difference of them
are 7.08, 8.5, and 13.58 respectively (See Tab.7). Similarly, the pre and post
treatment mean values of Escitalopram+Alprazolam group for anxiety are 12.6
(±2.87SD) and 3.14 (±0.864SD), depression are 11.8 (±1.31SD) and 2.86(±0.77SD),
quality of life is 18.2 (±2.78SD) and 4.07 (±1.64SD), hence mean difference of
them are 9.46, 8.94, 14.13 respectively. Where as Clomipramine+Alprazolam group
exhibited the pre and post treating values for Anxiety as 10.8 (±1.93SD) and
2.70 (±1.06SD), for depression are 12.4 (±1.71SD) and 2.10 (±0.996SD), for quality of life is
17.4 (±3.10SD) and 5.20 (±1.69SD), hence mean difference of them are 8.1, 7.8,
12.2 respectively (See Tab 8).
The cost of the drugs per day is Escitalopram 3.00 Rs,
Clomipramine 2.00 Rs, and Alprazolam 1.00 Re (Tab: 9).The costs of the drugs
were assessed for one month. The total amount incurred by the patients for the
drugs alone was calculated in rupees. Escitalopram is Rs 180.00 per month.
Clomipramine is Rs 60.00 per month. Escitalopram+ Alprazolam the cost is Rs
240.00 per month. Clomipramine+ Alprazolam is Rs 120.00 per month (See Tab: 9).
DISCUSSION:
Above mean values confirm that, in single drug therapy
we can found that patients of Escitalopram group have more efficacies and
better quality of life than Clomipramine group, even though the cost per month
is slightly high for Escitalopram group. In two drug therapy, patients of
Escitalopram+Alprazolam group found to be more
effective and better quality of life than Clomipramine+Alprazolam group, even
though the cost per month is higher than Clomipramine+Alprazolam group.
Table: 8. MEAN DIFFERENCES FOR ANXIETY, DEPRESSION,
QUALITY OF LIFE AMONG THE STUDY GROUP [TWO DRUGS THERAPY]
|
Drugs [two
drug therapy] |
Mean
differnece for anxiety |
||
|
Anxiety |
Depression |
Quality
of life |
|
|
ESCITALOPRAM+ALPRAZOLAM |
9.46 |
8.94 |
14.13 |
|
CLOMIPRAMINE+ALPRAZOLAM |
8.1 |
7.8 |
12.2 |
From the above results it’s clear that SSRI (Selective
Serotonin reuptake Inhibitor) are the better choice of drug for anxiety and
depression. The efficacies demonstrated are better than tricyclic
antidepressants. These result is very
well correlated with the other studies5, 12.
Adding an anxiolytic agent to an antidepressant to
treat new episode of depression and anxiety disorders can be effective and this
is supported by the other studies10, 12.
Selective serotonin reuptake inhibitors produce
tremendous increase in expenditures per month when compared with tricyclic
antidepressants in our study and this is well supported by the other study11.In
our study, we found that Escitalopram is better than Clomipramine and this is
very well supported by the other studies5, 9, 12.Alprazolam may not
be the first choice of drug in the treatment of anxiety and depression, but it
was given along with antidepressants like selective serotonin reuptake
inhibitors and tricyclic antidepressants in our study.14.For
treating anxiety, antidepressants are
given to our study patients as the first choice of drugs and the use of
benzodiazepine as first line is very less. This is correlated with the other
study12.Efficacy of antidepressants like selective serotonin
reuptake inhibitors with benzodiazepines for anxiety disorder is more in our
study and this result is supported by the other study8.
CONCLUSION:
Anxiety and depression are a huge threat for the
public. Certainly anxiety and depression are highly co-morbid. If left
untreated, the majority of patients with anxiety develop depression where as
large numbers of depressed patients suffer from anxiety, if not an overt
anxiety.
In our hospital, Tricyclic Antidepressants and
Selective Serotonin Reuptake Inhibitors are the two class of drugs prescribed to
the patients as single drug therapy. Other classes of drugs prescribed are very
minimal. Tricyclic Antidepressants [Clomipramine] and in Selective Serotonin
Reuptake Inhibitors [Escitalopram] are the most commonly drugs prescribed to
the patients. In two drugs
|
DRUGS |
Unit Price in Rs. |
COST EXPENSE FOR A PATIENT PER MONTH IN RUPEES |
|
ESCITALOPRAM |
3 |
180.00 |
|
CLOMIPRAMINE |
2 |
60.00 |
|
ESCITALOPRAM+ALPRAZOLAM |
4 |
240.00 |
|
CLOMIPRAMINE+ALPRAZOLAM |
3 |
120.00 |
Table: 9. DATA SHOWING COST EXPENSE FOR A PATIENT PER MONTH
therapy, Escitalopram+Alprazolam and
Clomipramine+Alprazolam are the most prescribed drugs.
As a conclusion of the study, all the drugs prescribed
significantly improved the health condition of anxiety and depressive patients.
In single drug therapy Escitalopram is considered as the drug that has more
efficacies with respect to the mean values. Same way in two drug therapy
Escitalopram+Alprazolam combination has more efficacies with respect to the
mean values. The quality of life of the patients shows significant improvement,
it can be improved much more through patient awareness programs and patient
education.
Further it is evident that, the single drug therapy
itself is effective for the newly diagnosed patients. Regarding the cost
analysis, Escitalopram is quite costlier than Clomipramine in single drug
therapy and Escitalopram+Alprazolam are costly in two drugs therapy. Over all,
Escitalopram as a single drug therapy or as a two drug therapy with Alprazolam
has better efficacy in spite of the high cost.
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Received on 23.08.2009
Accepted on 10.09.2009
© A&V Publication all right reserved
Research J. Pharmacology and
Pharmacodynamics 2009; 1(1): 39-42