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Their antidepressant is expensive, and it isn’t selling well.

But the drug makers behind the medication are betting they can give it a boost by marketing it to treat a whole new category of depression symptoms — namely, cloudy thinking.

The catch: The Food and Drug Administration must first be persuaded that such symptoms can be treated as a separate category — and that the drug, sold as Brintellix, can treat it.


An FDA advisory committee meets Wednesday morning to debate whether cognitive dysfunction can be pulled out and treated as “a distinct entity,” separate from symptoms like pervasive sadness and apathy. That will set the stage for an afternoon vote on whether the FDA should approve Brintellix as the first treatment for the muddled thinking that often comes along with depression.

Drug makers Takeda Pharmaceuticals and Lundbeck are counting on approvals to create new demand for the drug and new justification to convince insurance companies to pay for it.


But experts say it’s not clear that Brintellix is any more effective than its competitors in making a difference for reversing depression’s cognitive complications.

“Clinically, in talking to my colleagues, we don’t really see any major differences in terms of cognitive effects between Brintellix and other drugs,” said Dr. Norman Sussman, a psychiatrist at New York University’s Langone Medical Center. “We don’t know that Prozac doesn’t do it as well. Or Zoloft. Or any of the other drugs.”

Brintellix, known generically as vortioxetine, was approved in 2013 for treating depression. And in a field dominated by generics, Brintellix stands out mostly for the hefty price tag it carries.

A 30-tablet regimen of the drug went for $290 late last year. Compare that with equivalent dosages of the many off-patent alternatives on the market: a generic version of Prozac sold by Vensun Pharmaceuticals has a $3 price tag, and a generic version of Zoloft sold by Northstar Rx goes for $5. (Those numbers, compiled by the research firm Truven Health Analytics, refer to the price that a manufacturer listed for a drug when it was sold to a wholesaler.)

That price gap has prompted health plans to balk when physicians try to prescribe Brintellix.

Clinicians often face a headache of paperwork demands from insurance companies when seeking justification for a Brintellix prescription, and many plans have formal policies in place to limit them. For example, the Michigan insurer HealthPlus will only cover Brintellix for patients who’ve struggled with dosage levels and have already tried at least three generic antidepressants.

That’s made many psychiatrists reluctant to prescribe Brintellix, or prompted them to only turn to it as a late resort for patients for whom other cheaper drugs have failed.

“I don’t want to start someone on something and know that they’re not going to be able to afford more than a week of it,” said Dr. Christopher Marano, a psychiatrist at Johns Hopkins University School of Medicine who specializes in treating depression in the elderly. “From my perspective, I don’t see any reason to jump right to Brintellix as a first-line agent right now.”

Takeda and Lundbeck’s investment in research to show that Brintellix can effectively treat the cognitive symptoms of depression — including problems with concentration, memory, and processing speed — is an effort to change that attitude among doctors.

Brintellix is angling to become the first drug approved for the treatment of cognitive symptoms caused by depression. Courtesy Takeda

Like all antidepressants on the market, Brintellix initially won FDA clearance on the back of studies that focused on mood-related symptoms. But Takeda and Lundbeck also ran two trials looking specifically at cognitive symptoms in patients who took the drug compared to those who took a placebo.

The results of those trials, which involved a total of 1,200 patients with moderate to severe depression, will be under the microscope when the FDA panel of mental health advisors meets this week at the agency’s White Oak Campus in Silver Spring, Md. The FDA doesn’t have to follow the panel’s recommendations, but it usually does. The agency has a deadline of March 28 to make a final decision on the expanded marketing application.

Takeda and Lundeck’s strategy follows a familiar playbook: Drug makers often try to boost sales of existing medications by looking for new indications that could help them stand out from the crowd. (Another typical approach, particularly for companies in the antidepressant market, is to invest in research to make the case that their drug causes fewer side effects than competitors.)

Brintellix appears to provide cognitive benefits, but anecdotal reports suggest that other antidepressants do, too.

But patients with depression and their doctors don’t have a good way to assess whether Brintellix is their best option because no trials — including the ones being used to support Brintellix’s application — have tested drugs head-to-head for their cognitive effects. And the makers of antidepressants that have gone generic have little incentive to invest in the kinds of rigorous clinical studies needed for FDA approval.

Dr. Roger McIntyre, a psychiatrist at the University of Toronto who led one of the trials supporting Brintellix’s FDA application, acknowledged that the lack of direct comparisons was a limitation. But he said he has other reasons to be optimistic about the drug.

Unlike many other antidepressants, which just block the reuptake of serotonin and other neurotransmitters, Brintellix can modulate the proteins that seratonin switches on, a mode of action which has downstream effects on other neurochemical systems. And compared to other antidepressants, Brintellix has more consistently spurred neuronal connections in brain cells when tested in a laboratory setting.

“We do have pieces of the puzzle that provide a robust scientific rationale that would lead us to believe that there’s something unique about this agent at the neurochemical level in the brain,” said McIntyre, who accepts consulting fees, speaking fees, and research support from Takeda, Lundbeck, and some of their competitors.

Neither Takeda nor Lundbeck made an executive available for an interview.

Clinically superior to its competitors or not, a new marketing authorization from the FDA would give Takeda and Lundbeck the ability to advertise Brintellix for that purpose, and to dispatch sales representatives to doctors’ offices to tout that use. Those factors would likely boost prescriptions by psychiatrists looking to help patients with cognitive symptoms — and make it harder for insurers to say no.

“The ammunition will be much stronger for clinicians if there’s a label that supports this drug being different from the others,” said Harry Tracy, a pharmaceutical industry consultant and the publisher of NeuroPerspective, a bimonthly publication focused on treatments for neurological and psychiatric diseases.

But first, the advisory committee that meets Wednesday must be convinced not only that Brintellix works, but also that cognitive dysfunction in depression can even be treated in the first place.

It’s hardly a given. There’s no clear view about how to diagnose depression-induced cognitive dysfunction, or what to measure in designing trials testing drugs that might be able to treat it.

But many patients and their families clearly see an unmet need.

Gary Girton, who suffered from severe depression for most of his life, found relief for years by working in his studio as a mosaic artist. Yet, as the cognitive symptoms of his depression intensified in the last year and a half of his life, it became harder for him to do what he loved.

Remembering where he’d left off on a project, distinguishing spacial elements, and being creative all became more frustrating until he stopped going to his studio. He died by suicide in 2014, at the age of 45.

His widower, Marlin Collingwood, now the executive director of the Massachusetts-based nonprofit Families for Depression Awareness, submitted written testimony that will be considered on Wednesday advocating for greater focus on the cognitive symptoms. (Girton never took Brintellix, and Collingwood won’t take a position on its application.)

“The fact that the FDA and pharma companies are seriously looking at ways to help those people deal with the cognitive side of things” Collingwood said, “is a very important step forward in the treatment of depression.”

  • This is the same john, and it’s a couple years later. Having taken Trintellix off and on since then, I have a little more perspective to share. First, withdrawal is a weird beast. I took it for a month at one point because I ran out of insurance and had to quit early. The withdrawal was the worst I ever had. I slept for a week and for several days was too dizzy to walk around without being completely misrable. Then later I took it for a period of about a year (I was able to get free samples). When I went off it that time I did the things I did the first time took Trintellix, I tapered down for maybe about a week and took a bunch of Omega 3 fish oil and magnesium supplements. No withdrawal.

    Second, I miss this stuff. Maybe it just worked for me better than most people, but I was happy all the time. Perpetually content, almost, with just enough down moments here and there to remind me how good it was to be alive the other 98% of the time. When something did bother me, it wouldn’t last past a decent night’s sleep.

  • The authors crude comparison of the price of generic Prozac and Zoloft, with the therapeutic effects of Trintellix, is well off the mark. In mood/ego sensitive patients Prozac yields mania and psychosis: Zoloft anti-anxiety effects are adverse in the withdrawn depressive: Trintellix has none of these side effects, and appears superior in its anti-depressive effects. Apples and oranges are not equivalent. While Trintellix should not be a first line choice, in my practice it is better tolerated, more effective, with fewer patients dropping out of treatment, and has a definite place in treatment, despite the costs.

    • Trintellix is definitely better than any other anti depressant on the market, but GP’s don’t want to prescribe it, without having seen a psychiatrist. It’s insane… Just an excuse. Probably because of the price for the NHS

  • I went on this medication after a genetic test ruled out a heck of a lot of AD’s for me. Over my life I’d also been on duloxetine, mirtazapine, buproprion, & fluoxetine. All but the mirtazapine had such a strong response with my noradrenaline receptors that I couldn’t tolerate them, my comorbid PTSD got significantly worse. Mirtazapine made me sleep 12 hours a night, and gain 30kg, but I was on it the longest (6 years). Vortioxetine is basically my last option, but it is ridiculously expensive. I wish they would prove its superiority in treatment of PTSD, not just MDD.

    • What sort of genetic test rules out AD meds? I did 23&me and didn’t see anything about depression. I thought this was just a guessing game with doctors to try and find a med that works?

  • As a high functioning individual, a psychiatrist/psychopharmacologist, bicultural, plagued with depression since childhood, I have been treated with every known antidepressant without satisfactory, sustained, remission, until I was given vortioxetine. I required a 20 mg dose to start, but the results are remarkable. The depression resolved, dosage reduced to 10mg qhs, cognitive improvement is impressive, side effects are minimal.

    • I am so glad I just read this. I am ASD and OCD. I just started taking this, today and was unsure. Thank you.

  • I’ve been on trintellix for about 6 weeks but now I’m fighting with my insurance. My income is too high to qualify for a government handout but Obama care is crap and even with the loyalty card from the manufacturer I still can’t afford it. Not sure what I’m going to do now.

    • If it helps, a generic should be out next year. It’s in it’s 6th year now and takes 7.

  • I didnt have Major Depression, just a little. The Doctor sent it to me, and At the beginning I was feeling good. But months later I began to have anxiety, sadness, maniac and suicidal ideas. But the doctor says is normal and to keep taking it for 3 more months.

    • You haven’t been diagnosed with MDD? Find another Psychiatrist and get a second opinion. If only for your own peace of mind.

  • If Lexapro is a cadillac, then Trintellix is a Tesla roadster. There is no comparison. I took Lexapro my first year out of law school and the “feel-not-stressed” was offset by a decimated short-term memory and 30 lbs added to my waistline over 6 months. I started Trintellix a week after my ex-wife moved out and that became the most pleasant year of my life. Maybe some weight gain, but noticeably sharper memory, short/mild withdrawal (when insurance changed and I had to stop taking it overnight), and nothing bothered me for more than a day.

    • Thank you John. Your review was by far the most comforting I’ve read so far. I have been given 2 weeks of samples by my psychiatrist to try and I’ve been really trying to educate myself before taking the first pill. I’ve never been on antidepressants, but should have been on something for years. I was just in denial for so long that now my memory is gotten terrible. I saw a neurologist, had a brain scan, did tests and there’s nothing neurologically wrong with me. Dr. was certain I am suffering depression and it’s affecting me as if I have memory loss. Thank you for being so candid about your experiences and the withdrawal being minimal. That had me very concerned, but it sounds like it’s not as bad as I thought it might be.

  • Addressing the cognitive effects is excellent. There definitely is a sense of fogginess of the cognition with depression. The ability to focus and to make plans are affected. Memory, especially short term, is definitely affected. The person feels like he/she is going about life with his/her head in a cloud. But, if this is so good for cognition, I would suspect that the pharmaceutical company can market it for Attention Deficit Hyperactivity Disorder. A consideration, huh? Strattera is an antidepressant also indicated for ADHD. It is similar to Wellbutrin, which is also used off label.

    • yeah, I have ADD and it didn’t help with that. Instead it made my tolerance to adderall go way up while (bad) while at the same time killing any withdrawal symptoms on days off (good). Honestly, they should consider it for recovering meth addicts, it probably does the same thing…

      As for Wellbutrin, once upon a time my Doctor had the same idea and prescribed it to me to supplement Adderoll. All I can say is try googling “Wellbutrin” along with “rage,” “uncontrollable anger,” “flash temper,” anything like that. I threw that stuff away real quick.

  • I have been taking trintellix for about a year. I just had a major change in insurance and found out I can no longer afford this prescription. This stuff cost way way too much. It has been a godsend for me. I don’t know what I’m going to do. This is a travesty and there should be a law. No other medication has worked for me.

    • I’m in basically the same boat. I started taking it and couldn’t believe the difference it made for me! I had my brain working again!

    • I am only on day 4. No side effects what so ever. The cognitive benefits are amazing without the irritablity of ADHD meds. I just feel like my brain finally works. It is very different than Zoloft. Zoloft was wonderful for depression but not for cognitive issues. It made me want to sleep 2 hours a day and I couldn’t get through my school workload because it did not help my processing disorder. I really hope this medication keeps working. I look forward to taking it every morning. It is expensive but you can get the cost down to 60$ for 10mg if you ask for a card from your Dr. If you can get the cost down you should try.

    • Ricki,
      I see this was a year ago and I am wondering what you ended up doing. I have been on Trintellix since it was Brintellix and it has been a God send. I am now in your shoes with the insurance. I went to fill it the other day. Although my insurance was paying $111 of it, I would have to pay an additional $253. I don’t know what to do.

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