Potential cost-effectiveness of therapeutic drug monitoring for depressed patients treated with citalopram.

BACKGROUND: For patients treated with citalopram, it was recently shown that serum concentrations above 50 ng/mL on day 7 of treatment are associated with an improved therapeutic outcome. The aim of this post hoc analysis was to calculate a potential cost-effectiveness of therapeutic drug monitoring (TDM) considering costs for hospitalization, medication, and drug analysis. METHODS: The study included patients with major depression. Weekly measurements of serum concentrations and assessments of psychopathology were conducted. RESULTS: Fifty-five patients were included in this analysis. For patients with high citalopram serum concentrations (>50 ng/mL), the mean duration of hospitalization was 49 ± 20 days, and it was 72 ± 37 days (P = 0.03) in the group with low drug concentrations (<50 ng/mL). Considering daily costs for hospitalization of 250€,;, the potential savings amounted to 5750€,; per patient for the 23 days. Assuming that 11% of the variation of duration of hospitalization per patient were attributed to the serum concentration of the drug, the resulting savings were 633€,; per patient. Considering the officially listed price of 21€,; per TDM assay, total costs for weekly measurements over a period of 10 weeks of hospitalization were 210€,;. In the groups with high and low serum concentrations, daily costs for citalopram medication were 3.00 ± 0.80€,; and 2.42 ± 0.70€,;, respectively (P = 0.002), and the mean number of comedications was nearly identical, that is, 1.87 ± 1.74 and 1.81 ± 1.86 drugs, respectively (P = 0.919). CONCLUSIONS: The data taken together indicate that TDM-guided dosing of citalopram has the potential to be cost effective by reducing the length of hospitalization.

Association between citalopram serum levels and clinical improvement of patients with major depression.

Imaging studies have shown that serum concentrations of the selective serotonin reuptake inhibitor citalopram correlate with serotonin transporter (5-HTT) occupancy in vivo. In patients with major depressive disorders treated with citalopram, 80% 5-HTT occupancy was considered to be necessary for maximal therapeutic effects, which requires citalopram serum concentrations of at least 50 ng/mL. The aim of this study was to compare treatment outcome in patients with citalopram serum concentrations greater than and less than 50 ng/mL after 7 days of treatment. This study included inpatients with acute major depressive disorder according to International Classification of Disease, 10th Revision who were treated with citalopram. In weekly intervals, the severity of depression was assessed with the 17-item Hamilton Depression Rating Scale (HAMD-17), and serum concentrations of citalopram were measured from baseline until week 5. Fifty-five patients were eligible for this analysis. After 7 days of treatment, 19 patients showed citalopram serum concentrations of 50 ng/mL or greater; 36 patients had lower concentrations. Patients at greater than the 50-ng/mL threshold had (i) lower mean HAMD-17 sum scores from day 7 to end point (P ≤ 0.018 for each analysis); (ii) a more pronounced HAMD-17 decrease (P ≤ 0.019 for each analysis), and (iii) 23 days' shorter duration of hospitalization (P = 0.033) than patients with levels of citalopram less than 50 ng/mL. As regards adverse effects, both patient groups were not significantly different. Despite therapeutic doses, a significant number of patients had serum concentrations less than 50 ng/mL, and these were associated with an unfavorable treatment outcome; therapeutic drug monitoring is recommended to optimize dosing citalopram in the early phase of treatment.

[Aggression of psychiatric patients--first results of a standardized documentation at the Gabersee district hospital]. / Aggressionen psychiatrischer Patienten--Erste Ergebnisse einer standardisierten Dokumentation des BZK Gabersee.

After a cluster of severe assaults against our staff we performed a standardized documentation concerning aggressive behaviour of in-patients at the BZK Gabersee, a major District Hospital with a typical spectrum of psychiatric patients. From July 1996 to March 2001 23037 patients were admitted and 1618 cases of aggressive behaviour were documented. About 75% of the patients were males, more than 50% were treated involuntarily. The aggressions were most frequently directed against the nursing staff, severe injuries occurred very rarely. We tried to analyse triggers and the individual motivations of aggressive behaviour. Countermeasures were often aggressive as well (reinforced medication, restraint e.g.). The results are discussed in the context of the literature, approaches to cope with and to reduce aggressions are mentioned briefly.

[Violence by Psychiatric In-Patients of the BZK Gabersee - First Results of a Standardized Documentation] / Aggressionen psychiatrischer Patienten - Erste Ergebnisse einer standardisierten Dokumentation des BZK Gabersee.

After a cluster of severe assaults against our staff we performed a standardized documentation concerning aggressive behaviour of in-patients at the BZK Gabersee, a major District Hospital with a typical spectrum of psychiatric patients. From July 1996 to March 2001 23 037 patients were admitted and 1618 cases of aggressive behaviour were documented. About 75 % of the patients were males, more than 50 % were treated involuntarily. The aggressions were most frequently directed against the nursing staff, severe injuries occured very rarely. We tried to analyse triggers and the individual motivations of aggressive behaviour. Countermeasures were often aggressive as well (reinforced medication, restraint e. g.). The results are discussed in the context of the literature, approaches to cope with and to reduce aggressions are mentioned briefly.