The need for an iterative process for assessing economic outcomes associated with SSRIs

Pharmacotherapeutic advances in the treatment of depression have included t he development of the selective serotonin reuptake inhibitors (SSRIs), ther eby providing alternatives to tricyclic antidepressants. Concurrent with th ese events have been significant structural (e.g. pharmaceutical formularie s) and regulatory (e.g. required pharmacoeconomic evaluations) changes in t he delivery, financing, and oversight of healthcare programmes throughout t he world. International cost-containment initiatives are increasingly manda ting a demonstration of value for money, defined in terms of a measurable h ealth and/or financial outcome, and, in the case of medicines, attributable to a given expenditure, for a given pharmacotherapeutic option. We examine the inherent strengths and weaknesses of 5 study designs used to discern a nd contrast financial outcomes stemming from the use of antidepressant phar macotherapy for the treatment of depressive illness [randomised controlled trials (RCTs); meta-analyses; decision-analytical models (DAMs); retrospect ive database investigations; randomised naturalistic inquiry]. We argue tha t the economic appraisal of pharmacotherapy requires an iterative process e xtending from the developmental (RCTs; meta-analyses; DAMs) through to the postmarketing phase (database reviews; naturalistic inquiry), thereby resul ting in a porfolio of evidence as to the safety, efficacy and effectiveness of a given pharmacotherapeutic category (e.g. SSRIs) and/or a specific med ication. Database reviews, while nonrandomised, and prospective naturalisti c inquiry afford greater insight into the patterns of use and financial mer its of prescribing specific pharmacotherapeutic options for the treatment o f depression within the context of clinical practice as compared with RCTs, meta-analyses and DAMs. The port folio of evidence to date indicates that the first-line use of SSRIs in the treatment of depression is clinically wa rranted, and represents value for money.