Comparative effectiveness of antidepressants for depression using EHRs from two health systems

Depression is a prevalent mental health condition, and many patients are treated in primary care, yet optimal antidepressant selection remains uncertain. Real-world data can help address gaps in understanding comparative effectiveness. We examined comparative effectiveness of duloxetine and vortioxetine in patients with depression and evaluated heterogeneity in patient characteristics, comorbidities, and healthcare utilization using electronic health records (EHR) from two large health systems.

We conducted a retrospective cohort study using EHR data from Duke University Health System (DUHS) and Johns Hopkins Health System (JHHS) from 2014 to 2021. Eligible participants were adult patients prescribed duloxetine or vortioxetine. We defined a Narrow Cohort requiring a concurrent depression diagnosis and a Broad Cohort based on prescription records. Comparative effectiveness analyses employed propensity score weighting methods. The primary outcome was all-cause hospitalization within one year of cohort entry. Secondary outcomes included emergency department (ED) visits, a composite of hospitalization or ED visit, suicidal encounters, medication switching (either between the study drugs or from the study drugs to other psychiatric medications), and change in PHQ-9 score.

The Narrow Cohort included 3,337 (2,937 prescribed duloxetine and 400 vortioxetine) patients in DUHS and 3,237 (2,921 prescribed duloxetine and 316 vortioxetine) in the JHHS. Across both sites, vortioxetine users were more likely to be white, privately insured, and to have prior psychiatric medication use, while duloxetine users had higher comorbidity burden. Hospitalization rates were similar between treatments in both systems (OR_DUHS: 0.84 [95% CI: 0.45, 1.58], OR_JHHS: 0.7 [0.47, 1.03]). Estimates for ED visits, composite outcomes, and suicidal encounters were also comparable. Vortioxetine users had higher odds of switching medications among DUHS patients (OR_DUHS: 1.75 [1.37, 2.23]) and JHHS patients (OR_JHHS: 1.31 [0.97, 1.77]). Findings were largely consistent between the Narrow and Broad Cohorts.

Comparative effectiveness estimates for duloxetine and vortioxetine using EHR data were largely consistent across two health systems, with no meaningful differences for most outcomes. Consistent findings across two cohorts support the robustness and generalizability of these results. These results suggest that harmonized multi-site EHR data can provide reliable evidence while highlighting the importance of accounting for health system context.

Not applicable.