Eduard Kakariqi MD, MSc, PhD, Professor Laerta Kakariqi MD, PhD Sonila Vito PhD

1. Ambulatory consumption of Antidepressant drugs in Albania 2004-2014 -Comparison between HII data and Import data Eduard Kakariqi MD, MSc, PhD, Professor Laerta Kakariqi MD, PhD Sonila Vito PhD

2. Aim: To assess the out-of-hospital antidepressant drugs use in Albania during the period 2004-2014 . Materials and Methods: The data were obtained from the HII. All data were collected for the period 2004-2014 and analyzed. The data about the population were obtained from the Institute of Statistics (INSTAT). The data about the consumption of drugs were expressed as a number of Defined Daily Dose (DDDs)/1000 inhabitants/day. All drugs were classified by groups of Anatomic Therapeutic Chemical Classification (ATC). Data on real consumption (import and domestic production) For all the period under study 2004-2014 there were collected and analysed data from the import and domestic production of the drugs, which represent the real consumption of drugs in the country.

3. Results The data were expressed as a number of defined daily doses per 1000 inhabitants/day (DDDs/1000 inhabitants/day). There are only four antidepressant drugs included in the reimbursement list. The total annual consumption of antidepressant drugs varies 0.66-1.22 DDD/1000 inhabitants/day, respectively for 2004-2014, i.e. with a slight increase. The drugs included in the reimbursement scheme are: amitriptyline, clomipramine, imipramine, maprotiline, fluoxetine. The most prescribed was Amitriptyline 0.37-0.53 DDD/1000 inhabitants/day, respectively for 2004-2014, showing a great difference compared to the other antidepressant drugs. Meanwhile the consumption of Fluoxetine is 0.04-0.58 DDD/1000 inhabitants/day (2004-2014), which is the only drug with a slight consumption increase, but the values are marginal in comparison with other countries.

4. Depressive morbidity data indicate that there does not exist any correlation statistically significant between this disease and the trend of consumption of antidepressant drugs (p = 0,0945) (Figure 1). Figure 1 Consumption of Antidepressant drugs at the national level (DDD/1000 inhabitants/day) versus depressive morbidity (cases/1000 inhabitants); (p = 0,1097; strength (with significance level ≤ 0,05) = 35,05%; correlation coeficient is not statistically significant).

5. Figure 2 Annual average value of consumption of Antidepressant drugs: consumption based on import (real consumption) [*] versus consumption based on HII. [*] The “Import” item includes the consumption based on import data as well as the consumption based on domestic production: this represents the factual consumption.

6. Figure 4 International comparison of consumption of Antidepressants Italy, Estonia, Norway, Finland, (DDD/1000 inhabitants/day).

7. Discussion • There can be noted (in Figure 1) an evident discrepancy between the reported level of depressive morbidity and the consumption of antidepressant drugs, which indicates a very low coverage of the treatment with antidepressants by the scheme. • The consumption based on HII consists in only 20% of the real consumption of this class. The real consumption covers convincingly the morbidity values, by even exceeding them. • Possible reasons of this notable deviation of antidepressant drugs out of the scheme may be the avoidance of the family doctor and their obtainment directly in pharmacy. • This is considering the non-appropriate educational and social level of the population and the high level of stigmatization of this disease from the public opinion. Another important reason is the poor coverage by the scheme on the most necessary therapeutic alternatives of antidepressants.

8. International comparisons on the consumption Compared to other countries (Figure 4), it is clear that the consumption and prescription of antidepressants in our country continues to be remain at much lower values, which indicated their under-usage in Albania. Conclusions There is an increase in antidepressant drugs use from HII covering, while there is a significant increase in their use from out-of-pocket expenditure during 2004-2014. In comparison with the data of similar studies in other countries, it appeared that the consumption of antidepressant drugs in Albania is still very low.

9. References 1. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: global burden of disease study. Lancet 1997; 349(9064):1498-1504. 2. Health Insurance Institute; Ministry of Health; 3. Institute of Statistics; INSTAT Albania 4. General Customs Directorate, Ministry of Finance, Albania 5. Gruppo di lavoro OsMed. L’uso dei farmaci in Italia. Rapporto nazionale anno 2009. Roma: Il Pensiero Scientifico Editore, 2010. www.agenziafarmaco.it 6. Gruppo di lavoro OsMed. L’uso dei farmaci in Italia. Rapporto nazionale gennaio-settembre 2010. Roma, dicembre 2010. www.agenziafarmaco.it 7. Gruppo di lavoro OsMed. L’uso dei farmaci in Italia Il Pensiero Scientifico Editore, 2011. 8. Ravimiamet State Agency of Medicines. Estonian Statistics on Medicines 2004-2006. Ravimiamet State Agency of Medicines,Ravimiamet 2007; ISSN 1406-0949. 9. Ravimiamet State Agency of Medicines. Estonian Statistics on Medicines 2006–2009. Ravimiamet State Agency of Medicines, Ravimiamet 2010; ISSN 1736-5813. 10. Statistical Yearbook of the State Agency of medicines 2015, ISSN 2228-2300 11. Norwegian Institute of Public Health. Drug Consumption in Norway 2006-2010. Department of pharmacoepidemiology, Norwegian Institute of Public Health; http://www.legemiddelforbruk.no. 12. Drug Consumption in Norway 2011-2015; ISSN:1890-9647 ISBN:978-82-8082-715-9 electronic version 13. Finnish Statistics on Medicines. Finnish Statistics on Medicines 2007. National Agency for Medicines, Department of safety and drug information; ISSN 0786-2180. 14. Finnish Statistics on Medicines. Finnish Statistics on Medicines 2009. National Agency for Medicines, Department of safety and drug information; ISSN 0786-2180. 15. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder. Am J Psychiatry 2000; 57(supp l4): 1-45 16. Geddes JR, Carney SM, Davies C, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 2003; 361:653-661. 17. Balwin DS, Anderson IM, Nutt DJ, et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19:567-596.

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