Comparative acceptability of first-line antidepressants among older adults using filled prescription sequences: A nationwide cohort study

Abstract

Objective: Differences in the effectiveness of antidepressant medications by age are uncertain, with no compelling evidence of medication outperforming others in older adults. This real-world study compared the acceptability (efficacy and tolerability) of 20 antidepressants in younger and older patients using filled prescription sequences.

Material and methods: A nationwide cohort from the French national health system (SNDS) identified new antidepressant users over one year. The primary outcome was clinical acceptability, measured by the continuation/change ratio over the six-month period after initiating first-line treatment. Continuation was defined as at least two refills of the same treatment. Change was defined as at least one filled prescription of another antidepressant, an antipsychotic medication, or a mood-stabilizer. Antidepressant medications were compared by clinical acceptability while stratifying on age (<65 vs ≥65 years). Multivariable logistic regression models were used to calculate odds ratios adjusted for sex, social deprivation, comorbidity, specialty of first prescriber and benzodiazepine or Z-drug prescriptions. To further examine the moderating effect of age, we searched for an age by medication interaction.

Results: Escitalopram had the highest acceptability in both participants aged <65 (n = 257,504) and ≥65 (n = 83,673). Acceptability substantially differed between groups, in particular for mianserin and mirtazapine, ranking 2nd and 7th in older patients and 15th and 19th among younger ones.

Conclusion: This large real-world study suggests differences in the acceptability of first-line antidepressants between older and younger patients. Although escitalopram ranked first regardless of age, alpha-2 blockers (mianserin and mirtazapine) emerged as acceptable options in older patients only.

Article summary: Differences in the effectiveness of antidepressant medications according to age are uncertain. In a nationwide cohort from the French national health system, filled prescription sequences were used to compare the acceptability of 20 antidepressants by patient age. The primary outcome was clinical acceptability measured by the continuation/change ratio over the six-month period following introduction of the first-line treatment. 257,504 participants aged <65 and 83,673 aged ≥65 were included. Acceptability substantially differed between age groups.

Keywords: Acceptability; Administrative claims; Age; Antidepressant; Antidepressant agents; Big data; Cohort studies; Depression; Depressive disorder; Efficacy; Geriatric psychiatry; Healthcare; National health data system; Ranking; Reimbursement.