우울증 치료 시 항우울제 선택에 관한 비용-효과 분석
Cost-effectiveness analysis of antidepressants in treatment of major depressive disorder
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초록
우울증은 사회적 부담이 상당히 큰 질환으로 WHO는 오는 2020년에 이르면 질병부담이 두 번째로 높은 질환이 될 것으로 예측하고 있다. 우리나라의 자살로 인한 사망률은 OECD국가 중 가장 높은 것으로 보고되며, 이러한 자살의 원인 중 60%를 차지하는 것이 우울증이다. 이에 본 연구에서는 중등도 및 중증 우울증 환자를 대상으로 국내 시장점유율이 높은 항우울제 4개성분 (venlafaxine, paroxetine, escitalopram, mirtazapine)에 대한 비용-효과 분석을 통하여, 우울증 치료 시 보다 합리적이고 비용 효과적인 약제를 선택할 수 있도록 기초자료를 제공하고자 한다. 결정수형모형을 이용하여 6개월간의 증가된 질보정생존연수(QALY)를 측정하였으며, 비용에는 직접의료비용과 간접비용이 포함되었다. 기본 분석 결과, 효과는 escitalopram> venlafaxine> mirtazapine > paroxetine 순으로 escitalopram이 가장 효과적인 것으로 나타났으며, 비용은 escitalopram이 가장 적고 venlafaxine< mirtazapine < paroxetine 순으로 높아졌다. 점진적 비용-효과비(ICER)를 구한 결과, escitalopram은 나머지 3개 약제에 비해 효과는 좋으면서 비용은 더 적어 가장 비용 효과적인 것으로 나타났다. 이러한 결과는 효과 및 비용 등의 주요변수에 대한 민감도 분석에서도 달라지지 않았으며, escitalopram의 비용-효과성에 가장 크게 영향을 미치는 요인은 저렴한 약제비와 낮은 부작용발생률임을 알 수 있었다.
Abstract
The economic burden of depression is known to be high and was estimated 2,015.3 billion won in Korea. The purpose of this analysis was to evaluate the cost-effectiveness of first-line therapies (escitalopram, paroxetine, venlafaxine, mirtazapine) for the treatment of major depressive disorder (MDD) in Korea. A decision analytic model with a 6 month treatment goal was used to estimate the effectiveness, cost and cost-effectiveness of antidepressants from the societal perspective. Clinical outcome was measured using quality-adjusted life years(QALY) based on remission rates(HAM-D≤7 or MADRS≤10) and adverse drug reaction(ADR) rates. Sensitivity analysis was conducted to examine the impact of uncertainty upon variation of the major parameters. The expected effectiveness of treatment was 0.3700 QALY for escitalopram, followed by 0.3684 for venlafaxine, 0.3675 QALY for mirtazapine and 0.3557 QALY for paroxetine. The total cost of treatment was 6,621,107 won for escitalopram, 6,799,101 won for venlafaxine, 6,830,130 won for mirtazapine and 7,801,911 won for paroxetine. The most effective and the least expensive alternative, escitalopram was dominant compared with other three antidepressants. Sensitivity analyses indicated that the results of the study were robust to the assumptions underpinning the model. This analysis suggests that first-line treatment of MDD with escitalopram is the most cost-effective alternative compared with mirtazapine, venlafaxine, paroxetine in the Korea National Health Insurance context. The observed dominance reported in the current study stems from better clinical outcomes and cost savings demonstrated by escitalopram over the 3 comparators.
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