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Jorgensen A, Larsen EN, Sloth MMB, Kessing LV, Osler M. Prescription patterns in unipolar depression: A nationwide Danish register-based study of 113,175 individuals followed for 10 years. Acta Psychiatr Scand 2024; 149:88-97. [PMID: 37990476 DOI: 10.1111/acps.13640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Evidence-based use of antidepressant medications is of major clinical importance. We aimed to uncover precription patterns in a large cohort of patients with unipolar depression. MATERIAL AND METHODS Using Danish nationwide registers, we identified individuals with a first-time hospital diagnosis of unipolar depression between January 1st, 2001, and December 31st, 2016. Redemeed prescriptions of antidepressants from five years before to five years after diagnosis were retreived. Lithium and relevant antipsychotics were included. Data were analyzed with descriptive statistics including sunburst plots. Cox regressions were used to rank the risk of treatment failure according to antidepressant category and depression severity, as measured by hazard ratios of drug shift. RESULTS The full study population consisted of 113,175 individuals. Selective Serotonin Reuptake Inhibitors was the predominantly prescribed first-line group, both before (55.4%) and after (47.7%) diagnosis and across depression severities. Changes of treatment strategy were frequent; 60.8%, 33.7%, and 17.1% reached a second, third, and fourth treatment trial after the hospital diagnosis, respectively. More than half of patients continued their pre-diagnosis antidepressant after diagnosis. The risk of change of treatment strategy was generally lower in mild-moderate depression and higher in severe depression, with tricyclic antidepressants carrying the highest risk in the former and the lowest risks in the latter. Overall, prescribing were often not in accordance with guidelines. CONCLUSION These findings uncover a potential for improving the clinical care for patients with unipolar depression through optimization of the use of marketed antidepressants.
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Affiliation(s)
- Anders Jorgensen
- Copenhagen Affective Disorder research Center (CADIC), Psychiatric Center Copenhagen, Frederiksberg, Denmark
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen K, Denmark
| | - Emma Neble Larsen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | | | - Lars Vedel Kessing
- Copenhagen Affective Disorder research Center (CADIC), Psychiatric Center Copenhagen, Frederiksberg, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen N, Denmark
| | - Merete Osler
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen K, Denmark
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
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Accinni T, Panfili M, Tarsitani L, Biondi M, Pasquini M, Maraone A. A Revision on the Effectiveness of Omega-3 Polyunsaturated Fatty Acids as Monotherapy in the Treatment of Major Depressive Disorder. Int J Clin Pract 2022; 2022:3801235. [PMID: 36474548 PMCID: PMC9683950 DOI: 10.1155/2022/3801235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Insufficient effectiveness and a difficult tolerability profile of antidepressant drugs for the treatment of major depressive disorder (MDD) have been reported, and polyunsaturated fatty acids (PUFAs) have been posited as reliable therapeutic alternatives. The present study investigated the efficacy of omega-3 PUFAs as monotherapy for MDD. METHODS Two well-trained reviewers independently looked at the most significant randomized clinical trials (RCTs) from the PubMed database regarding PUFAs' employment in MDD compared to placebo; "major depressive disorder" and "omega-3 fatty acids," or "omega-6 fatty acids," or "polyunsaturated fatty acids (PUFA)," or "n - 3 polyunsaturated fatty acids," or "eicosapentaenoic acid (EPA)," or "docosahexaenoic acid (DHA)" were used as the medical subject keywords. RESULTS Of the initial 96 potential RCTs based on titles and abstracts, 82 studies did not meet the inclusion criteria and were excluded. Six studies were excluded from the remaining 14 after full text revision. Eight RCTs met all the inclusion/exclusion criteria without reporting clear evidence of PUFAs' effectiveness in the treatment of MDD. CONCLUSION At present, there is no opportunity to recommend the use of omega-3 PUFAs monotherapy for the treatment of MDD, although their supplementation may be useful in some specific populations.
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Affiliation(s)
- Tommaso Accinni
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Universitá 30, 00185 Rome, Italy
| | - Matteo Panfili
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Universitá 30, 00185 Rome, Italy
| | - Lorenzo Tarsitani
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Universitá 30, 00185 Rome, Italy
| | - Massimo Biondi
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Universitá 30, 00185 Rome, Italy
| | - Massimo Pasquini
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Universitá 30, 00185 Rome, Italy
| | - Annalisa Maraone
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Universitá 30, 00185 Rome, Italy
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Johnson CF, Maxwell M, Williams B, Dougall N, MacGillivray S. Dose-response effects of selective serotonin reuptake inhibitor monotherapy for the treatment of depression: systematic review of reviews and meta-narrative synthesis. BMJ MEDICINE 2022; 1:e000017. [PMID: 36936596 PMCID: PMC9978765 DOI: 10.1136/bmjmed-2021-000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/05/2022] [Indexed: 12/04/2022]
Abstract
Objective To assess and clarify the relations between selective serotonin reuptake inhibitor (SSRI) dose efficacy, acceptability (early treatment discontinuation (dropouts)), and tolerability (reported adverse drug effects), and critically evaluate methods previously used to examine SSRI dose-response effects for the treatment of depression in adults. Design Systematic review of reviews and meta-narrative synthesis. Data sources Embase, Medline, PsycINFO, Scopus, and the Cochrane Collaboration library, from 1975 to December 2021. Reference lists of national depression treatment guidelines were systemically searched by hand. Eligibility criteria for selecting studies Reviews assessing SSRI monotherapy dose-response effects for the treatment of depression in adults (age ≥18 years) reporting efficacy, acceptability, or tolerability. Reviews meeting inclusion criteria had a high degree of heterogeneity, due to methodological diversity; therefore, a meta-narrative synthesis approach was applied. Standard daily doses were defined as 20 mg citalopram, fluoxetine, paroxetine; 50 mg sertraline; and 10 mg escitalopram. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool, in line with Cochrane recommendations. Results The search identified 9138 records; 387 full text reports were assessed for eligibility, 42 of which matched the inclusion criteria. The majority, 83% (n=35), of reviews included data for studies with a duration of ≤12 weeks (ie, the acute phase of depression treatment). Of 39 reviews assessing efficacy, the majority (n=26) indicated that individual SSRIs and SSRI class demonstrated flat dose-response effects; standard doses were optimal for efficacy. Acceptability or tolerability were assessed in 28 reviews. Higher than standard daily doses were associated with higher dropout rates and a greater incidence of adverse drug effects (eg, nausea, sexual dysfunction, fatigue, anxiety). Despite a range of methods being reported, there was an overall consensus regarding SSRI dose related efficacy, dropouts, and adverse drug effects. Conclusion Standard daily doses of SSRIs for the treatment of depression in adults provide a favourable balance between efficacy, acceptability, and tolerability. Patients are encouraged to talk to their prescriber or community pharmacist if they experience adverse effects or have any concerns about their drug treatments.
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Affiliation(s)
- Chris F Johnson
- Pharmacy Services, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Margaret Maxwell
- Midwifery and AHP Research Unit, University of Stirling, Stirling, UK
| | - Brian Williams
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Nadine Dougall
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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A randomized controlled double-blind clinical trial comparing versus placebo the effect of an edible algal extract (Ulva Lactuca) on the component of depression in healthy volunteers with anhedonia. BMC Psychiatry 2018; 18:215. [PMID: 29954354 PMCID: PMC6027788 DOI: 10.1186/s12888-018-1784-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 06/12/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The effects of the seaweed extract were evaluated on the animal model equivalent of depression compared with a control group treated with the carrier (spring water) and a reference group treated with Imipramine and showed significative effect. This clinical trial was intended to confirm in humans the potential efficacy identified in animals. The primary objective was to compare against a placebo the effect of Ulva L.L extract in healthy volunteers whose anhedonia was characterized by a component of depression. METHODS Single-centre double-blind randomized placebo-controlled clinical trial on parallel arms of two groups of 45 subjects. The study could include men or women aged 18 to 65 years with anhedonia characterized by a Snaith Hamilton Pleasure Scale score (SHAPS) of ≥5 and feeling low morale for at least four weeks characterized by a component of depression evaluated on the Quick Inventory of Depressive Symptomatology - Self Report (QIDS-SR). Evaluation criteria: QIDS-SR; Patient Global Improvement Impression (PGII) and Clinical Global Improvement Impression (CGII). RESULTS 86 subjects were included in the trial: 42 in the placebo group and 44 Ulva group. At D84, QIDS-SR significantly decreased more in the Ulva.L.L. group than in the placebo group (p: 0.0389). This difference is essentially linked to an improvement of the sleep disorders (p: 0.0219), of the psychomotor consequences (p: 0.002) and of the nutrition behaviour (p: 0.0694). 90.1% have the feeling of being improved in the Ulva group vs 72.5% in the placebo group (p: 0.0114) and in parallel 90.9% of the practitioners have the feeling that the subject has improved vs 70.8% (p: 0.0214). CONCLUSION This double-blind randomized placebo-controlled trial shows that daily intake for three months of a water-soluble extract of Ulva L.L. continues to significantly improve the component of depression of subjects presenting anhedonia compared with a placebo. TRIAL REGISTRATION Trial retrospectively registred on ClinicalTrial.gov under ID: NCT03545399 Date: 05/22/2018.
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Wadhwa R, Kumar M, Talegaonkar S, Vohora D. Serotonin reuptake inhibitors and bone health: A review of clinical studies and plausible mechanisms. Osteoporos Sarcopenia 2017; 3:75-81. [PMID: 30775508 PMCID: PMC6372777 DOI: 10.1016/j.afos.2017.05.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/02/2017] [Accepted: 05/19/2017] [Indexed: 01/05/2023] Open
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are currently the treatment of choice in depression and constitute major portion of prescription in depressive patients. The role of serotonin receptors in bone is emerging, raising certain questions regarding the effect of blockade of serotonin reuptake in the bone metabolism. Clinical studies have reported an association of SSRI antidepressants which with increase in fracture and decrease in bone mineral density. This review focus on recent evidence that evaluate the association of SSRIs with the risk of fracture and bone mineral density and also the probable mechanisms that might be involved in such effects.
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Affiliation(s)
- Ravisha Wadhwa
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Manoj Kumar
- Pharmaceutical Medicine, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Sushama Talegaonkar
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Divya Vohora
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India.,Pharmaceutical Medicine, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
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Quilty LC, Marshe V, Lobo DSS, Harkness KL, Müller DJ, Bagby RM. Childhood Abuse History in Depression Predicts Better Response to Antidepressants with Higher Serotonin Transporter Affinity: A Pilot Investigation. Neuropsychobiology 2017; 74:78-83. [PMID: 28064281 DOI: 10.1159/000453549] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 11/03/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Childhood abuse is a powerful prognostic indicator in adults with major depressive disorder (MDD) and is associated with numerous biological risk factors for depression. The purpose of this investigation was to explore if antidepressant medication affinity for the serotonin transporter moderates the association between childhood abuse and treatment response. METHODS Our sample included 52 outpatients with MDD who had received up to 26 weeks of pharmacotherapy, stratifying antidepressant medications with a high versus a low affinity for the serotonin transporter. Patients completed the Hamilton Rating Scale for Depression, Beck Depression Inventory II, Home Environment Questionnaire, and Ontario Health Supplement: Child Abuse and Trauma Scale to assess depression and childhood abuse. RESULTS Medication class moderated the link between 3 indices of childhood abuse and treatment response such that higher levels of childhood abuse were associated with higher levels of depression severity after treatment only in those patients receiving antidepressant medications with a weak affinity for the serotonin transporter. CONCLUSIONS This pilot study suggested that prolonged exposure to stress during childhood may result in biological vulnerabilities for depression, which may in turn be differentially targeted by pharmacological agents which target serotonin to a greater or lesser degree.
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Affiliation(s)
- Lena C Quilty
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
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Martean L, Evans C. Prescribing for personality disorder: qualitative study of interviews with general and forensic consultant psychiatrists. PSYCHIATRIC BULLETIN (2014) 2014; 38:116-21. [PMID: 25237521 PMCID: PMC4115371 DOI: 10.1192/pb.bp.113.044081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 09/18/2013] [Accepted: 09/23/2013] [Indexed: 11/25/2022]
Abstract
Aims and method To explore experiences of psychiatrists considering medication for patients with personality disorder by analysis of transcribed, semi-structured interviews with consultants. Results Themes show important relational processes in which not prescribing is expected to be experienced as uncaring rejection, and psychiatrists felt helpless and inadequate as doctors when unable to relieve symptoms by prescribing. Discontinuity in doctor-patient relationships compounds these problems. Clinical implications Problems arise from: (a) the psychopathology creating powerful relational effects in consultation; (b) the lack of effective treatments, both actual and secondary to under-resourcing and neglect of non-pharmaceutical interventions; and (c) the professionally constructed role of psychiatrists prioritising healing and cure through provision of technological interventions for specific diagnoses. There is a need for more treatments and services for patients with personality disorder; more support and training for psychiatrists in the relational complexities of prescribing; and a rethink of the trend for psychiatrists to be seen primarily as prescribers.
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Won E, Park SC, Han KM, Sung SH, Lee HY, Paik JW, Jeon HJ, Lee MS, Shim SH, Ko YH, Lee KJ, Han C, Ham BJ, Choi J, Hwang TY, Oh KS, Hahn SW, Park YC, Lee MS. Evidence-based, pharmacological treatment guideline for depression in Korea, revised edition. J Korean Med Sci 2014; 29:468-84. [PMID: 24753693 PMCID: PMC3991789 DOI: 10.3346/jkms.2014.29.4.468] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 02/07/2014] [Indexed: 12/12/2022] Open
Abstract
This paper aims to introduce, summarize, and emphasize the importance of the 'Evidence-Based, Pharmacological Treatment Guideline for Depression in Korea, Revised Edition'. The guideline broadly covers most aspects of the pharmacological treatment of patients in Korea diagnosed with moderate to severe major depression according to the DSM-IV TR. The guideline establishment process involved determining and answering a number of key questions, searching and selecting publications, evaluating recommendations, preparing guideline drafts, undergoing external expert reviews, and obtaining approval. A guideline adaptation process was conducted for the revised edition. The guideline strongly recommends pharmacological treatment considered appropriate to the current clinical situation in Korea, and should be considered helpful when selecting the appropriate pharmacological treatment of patients diagnosed with major depressive disorder. Therefore, the wide distribution of this guideline is recommended.
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Affiliation(s)
- Eunsoo Won
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | - Seon-Cheol Park
- Department of Psychiatry, Yong-In Mental Hospital, Yongin, Korea
| | - Kyu-Man Han
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | - Seung-Hwan Sung
- Department of Psychiatry, College of Medicine, Soonchunhyang University, Asan, Korea
| | - Hwa-Young Lee
- Department of Psychiatry, College of Medicine, Soonchunhyang University, Asan, Korea
| | - Jong-Woo Paik
- Department of Psychiatry, School of Medicine, KyungHee University, Seoul, Korea
| | - Hong Jin Jeon
- Department of Psychiatry, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Moon-Soo Lee
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | - Se-Hoon Shim
- Department of Psychiatry, College of Medicine, Soonchunhyang University, Asan, Korea
| | - Young-Hoon Ko
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | - Kang-Joon Lee
- Department of Psychiatry, College of Medicine, Inje Universtiy, Busan, Korea
| | - Changsu Han
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | - Byung-Joo Ham
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | - Joonho Choi
- Department of Psychiatry, College of Medicine, Hanyang University, Seoul, Korea
| | - Tae-Yeon Hwang
- Department of Psychiatry, Yong-In Mental Hospital, Yongin, Korea
| | - Kang-Seob Oh
- Department of Psychiatry, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Sang-Woo Hahn
- Department of Psychiatry, College of Medicine, Soonchunhyang University, Asan, Korea
| | - Yong-Chon Park
- Department of Psychiatry, College of Medicine, Hanyang University, Seoul, Korea
| | - Min-Soo Lee
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
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Magni LR, Purgato M, Gastaldon C, Papola D, Furukawa TA, Cipriani A, Barbui C. Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database Syst Rev 2013:CD004185. [PMID: 24353997 DOI: 10.1002/14651858.cd004185.pub3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Depression is common in primary care and is associated with marked personal, social and economic morbidity, thus creating significant demands on service providers. The antidepressant fluoxetine has been studied in many randomised controlled trials (RCTs) in comparison with other conventional and unconventional antidepressants. However, these studies have produced conflicting findings.Other systematic reviews have considered selective serotonin reuptake inhibitor (SSRIs) as a group which limits the applicability of the indings for fluoxetine alone. Therefore, this review intends to provide specific and clinically useful information regarding the effects of fluoxetine for depression compared with tricyclics (TCAs), SSRIs, serotonin-noradrenaline reuptake inhibitors (SNRIs), monoamineoxidase inhibitors (MAOIs) and newer agents, and other conventional and unconventional agents. OBJECTIVES To assess the effects of fluoxetine in comparison with all other antidepressive agents for depression in adult individuals with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group Controlled Trials Register (CCDANCTR)to 11May 2012. This register includes relevant RCTs from the Cochrane Central Register of Controlled Trials (CENTRAL) (all years),MEDLINE (1950 to date), EMBASE (1974 to date) and PsycINFO (1967 to date). No language restriction was applied. Reference lists of relevant papers and previous systematic reviews were handsearched. The pharmaceutical company marketing fluoxetine and experts in this field were contacted for supplemental data. SELECTION CRITERIA All RCTs comparing fluoxetine with any other AD (including non-conventional agents such as hypericum) for patients with unipolar major depressive disorder (regardless of the diagnostic criteria used) were included. For trials that had a cross-over design only results from the first randomisation period were considered. DATA COLLECTION AND ANALYSIS Data were independently extracted by two review authors using a standard form. Responders to treatment were calculated on an intention-to-treat basis: dropouts were always included in this analysis. When data on dropouts were carried forward and included in the efficacy evaluation, they were analysed according to the primary studies; when dropouts were excluded from any assessment in the primary studies, they were considered as treatment failures. Scores from continuous outcomes were analysed by including patients with a final assessment or with the last observation carried forward. Tolerability data were analysed by calculating the proportion of patients who failed to complete the study due to any causes and due to side effects or inefficacy. For dichotomous data, odds ratios (ORs) were calculated with 95% confidence intervals (CI) using the random-effects model. Continuous data were analysed using standardised mean differences (SMD) with 95% CI. MAIN RESULTS A total of 171 studies were included in the analysis (24,868 participants). The included studies were undertaken between 1984 and 2012. Studies had homogenous characteristics in terms of design, intervention and outcome measures. The assessment of quality with the risk of bias tool revealed that the great majority of them failed to report methodological details, like the method of random sequence generation, the allocation concealment and blinding. Moreover, most of the included studies were sponsored by drug companies, so the potential for overestimation of treatment effect due to sponsorship bias should be considered in interpreting the results. Fluoxetine was as effective as the TCAs when considered as a group both on a dichotomous outcome (reduction of at least 50% on the Hamilton Depression Scale) (OR 0.97, 95% CI 0.77 to 1.22, 24 RCTs, 2124 participants) and a continuous outcome (mean scores at the end of the trial or change score on depression measures) (SMD 0.03, 95% CI -0.07 to 0.14, 50 RCTs, 3393 participants). On a dichotomousoutcome, fluoxetine was less effective than dothiepin or dosulepin (OR 2.13, 95% CI 1.08 to 4.20; number needed to treat (NNT) =6, 95% CI 3 to 50, 2 RCTs, 144 participants), sertraline (OR 1.37, 95% CI 1.08 to 1.74; NNT = 13, 95% CI 7 to 58, 6 RCTs, 1188 participants), mirtazapine (OR 1.46, 95% CI 1.04 to 2.04; NNT = 12, 95% CI 6 to 134, 4 RCTs, 600 participants) and venlafaxine(OR 1.29, 95% CI 1.10 to 1.51; NNT = 11, 95% CI 8 to 16, 12 RCTs, 3387 participants). On a continuous outcome, fluoxetine was more effective than ABT-200 (SMD -1.85, 95% CI -2.25 to -1.45, 1 RCT, 141 participants) and milnacipran (SMD -0.36, 95% CI-0.63 to -0.08, 2 RCTs, 213 participants); conversely, it was less effective than venlafaxine (SMD 0.10, 95% CI 0 to 0.19, 13 RCTs,3097 participants). Fluoxetine was better tolerated than TCAs considered as a group (total dropout OR 0.79, 95% CI 0.65 to 0.96;NNT = 20, 95% CI 13 to 48, 49 RCTs, 4194 participants) and was better tolerated in comparison with individual ADs, in particular amitriptyline (total dropout OR 0.62, 95% CI 0.46 to 0.85; NNT = 13, 95% CI 8 to 39, 18 RCTs, 1089 participants), and among the newer ADs ABT-200 (total dropout OR 0.18, 95% CI 0.08 to 0.39; NNT = 3, 95% CI 2 to 5, 1 RCT, 144 participants), pramipexole(total dropout OR 0.12, 95% CI 0.03 to 0.42, NNT = 3, 95% CI 2 to 5, 1 RCT, 105 participants), and reboxetine (total dropout OR0.60, 95% CI 0.44 to 0.82, NNT = 9, 95% CI 6 to 24, 4 RCTs, 764 participants). AUTHORS' CONCLUSIONS The present study detected differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain.Moreover, the assessment of quality with the risk of bias tool showed that the great majority of included studies failed to report details on methodological procedures. Of consequence, no definitive implications can be drawn from the studies' results. The better efficacy profile of sertraline and venlafaxine (and possibly other ADs) over fluoxetine may be clinically meaningful,as already suggested by other systematic reviews. In addition to efficacy data, treatment decisions should also be based on considerations of drug toxicity, patient acceptability and cost.
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The role of the serotonergic system at the interface of aggression and suicide. Neuroscience 2013; 236:160-85. [PMID: 23333677 DOI: 10.1016/j.neuroscience.2013.01.015] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 01/01/2013] [Accepted: 01/05/2013] [Indexed: 02/07/2023]
Abstract
Alterations in serotonin (5-HT) neurochemistry have been implicated in the aetiology of all major neuropsychiatric disorders, ranging from schizophrenia to mood and anxiety-spectrum disorders. This review will focus on the multifaceted implications of 5-HT-ergic dysfunctions in the pathophysiology of aggressive and suicidal behaviours. After a brief overview of the anatomical distribution of the 5-HT-ergic system in the key brain areas that govern aggression and suicidal behaviours, the implication of 5-HT markers (5-HT receptors, transporter as well as synthetic and metabolic enzymes) in these conditions is discussed. In this regard, particular emphasis is placed on the integration of pharmacological and genetic evidence from animal studies with the findings of human experimental and genetic association studies. Traditional views postulated an inverse relationship between 5-HT and aggression and suicidal behaviours; however, ample evidence has shown that this perspective may be overly simplistic, and that such pathological manifestations may reflect alterations in 5-HT homoeostasis due to the interaction of genetic, environmental and gender-related factors, particularly during early critical developmental stages. The development of animal models that may capture the complexity of such interactions promises to afford a powerful tool to elucidate the pathophysiology of impulsive aggression and suicidability, and identify new effective therapies for these conditions.
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Bloch MH, Hannestad J. Omega-3 fatty acids for the treatment of depression: systematic review and meta-analysis. Mol Psychiatry 2012; 17:1272-82. [PMID: 21931319 PMCID: PMC3625950 DOI: 10.1038/mp.2011.100] [Citation(s) in RCA: 217] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We conducted a meta-analysis of randomized, placebo-controlled trials of omega-3 fatty acid (FA) treatment of major depressive disorder (MDD) in order to determine efficacy and to examine sources of heterogeneity between trials. PubMed (1965-May 2010) was searched for randomized, placebo-controlled trials of omega-3 FAs for MDD. Our primary outcome measure was standardized mean difference in a clinical measure of depression severity. In stratified meta-analysis, we examined the effects of trial duration, trial methodological quality, baseline depression severity, diagnostic indication, dose of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in omega-3 preparations, and whether omega-3 FA was given as monotherapy or augmentation. In 13 randomized, placebo-controlled trials examining the efficacy of omega-3 FAs involving 731 participants, meta-analysis demonstrated no significant benefit of omega-3 FA treatment compared with placebo (standard mean difference (SMD)=0.11, 95% confidence interval (CI): -0.04, 0.26). Meta-analysis demonstrated significant heterogeneity and publication bias. Nearly all evidence of omega-3 benefit was removed after adjusting for publication bias using the trim-and-fill method (SMD=0.01, 95% CI: -0.13, 0.15). Secondary analyses suggested a trend toward increased efficacy of omega-3 FAs in trials of lower methodological quality, trials of shorter duration, trials which utilized completers rather than intention-to-treat analysis, and trials in which study participants had greater baseline depression severity. Current published trials suggest a small, non-significant benefit of omega-3 FAs for major depression. Nearly all of the treatment efficacy observed in the published literature may be attributable to publication bias.
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Affiliation(s)
- Michael H. Bloch
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT,Yale Child Study Center, Yale University School of Medicine, New Haven, CT
| | - Jonas Hannestad
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT
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Vöhringer PA, Ghaemi SN. Solving the antidepressant efficacy question: effect sizes in major depressive disorder. Clin Ther 2011; 33:B49-61. [PMID: 22136980 DOI: 10.1016/j.clinthera.2011.11.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 11/08/2011] [Accepted: 11/09/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND Numerous reviews and meta-analyses of the antidepressant literature in major depressive disorders (MDD), both acute and maintenance, have been published, some claiming that antidepressants are mostly ineffective and others that they are mostly effective, in either acute or maintenance treatment. OBJECTIVE The aims of this study were to review and critique the latest and most notable antidepressant MDD studies and to conduct our own reanalysis of the US Food and Drug Administration database studies specifically analyzed by Kirsch et al. METHODS We gathered effect estimates of each MDD study. In our reanalysis of the acute depression studies, we corrected analyses for a statistical floor effect so that relative (instead of absolute) effect size differences were calculated. We also critiqued a recent meta-analysis of the maintenance treatment literature. RESULTS Our reanalysis showed that antidepressant benefit is seen not only in severe depression but also in moderate depression and confirmed a lack of benefit for antidepressants over placebo in mild depression. Relative antidepressant versus placebo benefit increased linearly from 5% in mild depression to 12% in moderate depression to 16% in severe depression. The claim that antidepressants are completely ineffective, or even harmful, in maintenance treatment studies involves unawareness of the enriched design effect, which, in that analysis, was used to analyze placebo efficacy. The same problem exists for the standard interpretation of those studies, although they do not prove antidepressant efficacy either, since they are biased in favor of antidepressants. CONCLUSIONS In sum, we conclude that antidepressants are effective in acute depressive episodes that are moderate to severe but are not effective in mild depression. Except for the mildest depressive episodes, correction for the statistical floor effect proves that antidepressants are effective acutely. These considerations only apply to acute depression, however. For maintenance, the long-term efficacy of antidepressants is unproven, but the data do not support the conclusion that they are harmful.
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Affiliation(s)
- Paul A Vöhringer
- Facultad de Medicina, Hospital Clinico, Universidad de Chile, Santiago, Chile
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Omori IM, Watanabe N, Nakagawa A, Cipriani A, Barbui C, McGuire H, Churchill R, Furukawa TA. Fluvoxamine versus other anti-depressive agents for depression. Cochrane Database Syst Rev 2010:CD006114. [PMID: 20238342 PMCID: PMC4171125 DOI: 10.1002/14651858.cd006114.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated. OBJECTIVES Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti-depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs. SEARCH STRATEGY We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008. SELECTION CRITERIA We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression. DATA COLLECTION AND ANALYSIS Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies. MAIN RESULTS A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63). AUTHORS' CONCLUSIONS We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles.
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Affiliation(s)
- Ichiro M Omori
- Department of Psychiatry, Toyokawa City Hospital, Aichi, Japan
| | - Norio Watanabe
- Department of Psychiatry & Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Atsuo Nakagawa
- Department of Psychiatry and the Center for Clinical Research, Keio University School of Medicine, Tokyo, Japan
| | - Andrea Cipriani
- Department of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, Italy
| | - Corrado Barbui
- Department of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, Italy
| | - Hugh McGuire
- National Collaborating Centre for Women’s and Children’s Health, London, UK
| | - Rachel Churchill
- Centre for Mental Health, Addiction and Suicide Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Toshi A Furukawa
- Departments of Health Promotion and Behavior Change and of Clinical Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
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Nakagawa A, Watanabe N, Omori IM, Barbui C, Cipriani A, McGuire H, Churchill R, Furukawa TA. Milnacipran versus other antidepressive agents for depression. Cochrane Database Syst Rev 2009:CD006529. [PMID: 19588396 PMCID: PMC4164845 DOI: 10.1002/14651858.cd006529.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Although pharmacological and psychological interventions are both effective for major depression, antidepressant drugs are frequently used as first-line treatment in primary and secondary care settings. Milnacipran, a dual serotonin-norepinephrine reuptake inhibitor (SNRI), is one of the antidepressant drugs that clinicians use for routine depression care. OBJECTIVES To assess the evidence for the efficacy, acceptability and tolerability of milnacipran in comparison with tricyclic antidepressants (TCAs), heterocyclics, SSRIs and other newer antidepressive agents in the acute-phase treatment of major depression. SEARCH STRATEGY The Cochrane Collaboration Depression, Anxiety & Neurosis review group Controlled Trials Register (CCDANCTR-Studies and CCDANCTR-References) were electronically searched in August 2008. References of relevant trials and other reviews were also checked. Trial databases of the drug-approving agencies and ongoing clinical trial registers for all published and unpublished trials were hand-searched in 2007. All relevant authors were contacted for supplemental data. No language restriction was applied. SELECTION CRITERIA Randomised controlled trials comparing milnacipran with any other active antidepressive agents (including non-conventional agents such as herbal products like hypericum) as monotherapy in the acute phase of major depression were selected. DATA COLLECTION AND ANALYSIS Two reviewers independently checked eligibility, assessed methodological quality and extracted data from the eligible trials using a standardised data extraction form. The number of participants who responded to treatment or those who achieved remission were calculated on an intention-to-treat basis. Random-effects meta-analyses were conducted, combining data from the included trials. MAIN RESULTS A total of 16 randomised controlled trials (n=2277) were included in the meta-analysis.Despite the size of this sample, the pooled 95% confidence intervals were rather wide and there were no statistically significant differences in efficacy, acceptability and tolerability when comparing milnacipran with other antidepressive agents. However, compared with TCAs, patients taking milnacipran were associated with fewer dropouts due to adverse events (OR 0.55; 95%CI 0.35 to 0.85). There was also some weak evidence to suggest that patients taking milnacipran experienced fewer adverse events of sleepiness/ drowsiness, dry mouth or constipation compared with TCAs. AUTHORS' CONCLUSIONS Currently, there is inadequate evidence to conclude whether milnacipran is superior, inferior or the same as other antidepressive agents in terms of efficacy, acceptability and tolerability in the acute phase treatment of major depression. However, there is some evidence in favour of milnacipran over TCAs in terms of dropouts due to adverse events (acceptability) and the rates of experiencing adverse events (tolerability). Information about other clinically meaningful outcomes such as cost-effectiveness and social functioning, including the ability to return to work, is lacking. Further study is needed to answer whether milnacipran would be the better choice of antidepressant for acute major depression.
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Affiliation(s)
- Atsuo Nakagawa
- Department of Psychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Norio Watanabe
- Department of Psychiatry & Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ichiro M Omori
- Cochrane Schizophrenia Group, University of Nottingham, Nottingham, UK
| | - Corrado Barbui
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
| | - Andrea Cipriani
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
| | - Hugh McGuire
- National Coordinating Centre for Women and Child Health, London, UK
| | - Rachel Churchill
- Academic Unit of Psychiatry, Community Based Medicine, University of Bristol, Bristol, UK
| | - Toshi A Furukawa
- Department of Psychiatry & Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Cipriani A, Santilli C, Furukawa TA, Signoretti A, Nakagawa A, McGuire H, Churchill R, Barbui C. Escitalopram versus other antidepressive agents for depression. Cochrane Database Syst Rev 2009; 2016:CD006532. [PMID: 19370639 PMCID: PMC4164382 DOI: 10.1002/14651858.cd006532.pub2] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Although pharmacological and psychological interventions are both effective for major depression, antidepressant drugs remain the mainstay of treatment in primary and secondary care settings. During the last 20 years, antidepressant prescribing has risen dramatically in western countries, mainly because of the increasing consumption of selective serotonin reuptake inhibitors (SSRIs) and newer antidepressants, which have progressively become the most commonly prescribed antidepressants. Escitalopram is the pure S-enantiomer of the racemic citalopram. OBJECTIVES To assess the evidence for the efficacy, acceptability and tolerability of escitalopram in comparison with tricyclics, other SSRIs, heterocyclics and newer agents in the acute-phase treatment of major depression. SEARCH STRATEGY Electronic databases were searched up to July 2008. Trial databases of drug-approving agencies were hand-searched for published, unpublished and ongoing controlled trials. SELECTION CRITERIA All randomised controlled trials comparing escitalopram against any other antidepressant (including non-conventional agents such as hypericum) for patients with major depressive disorder (regardless of the diagnostic criteria used). DATA COLLECTION AND ANALYSIS Data were entered by two review authors (double data entry). Responders and remitters to treatment were calculated on an intention-to-treat basis. For dichotomous data, odds ratios (ORs) were calculated with 95% confidence intervals (CI). Continuous data were analysed using standardised mean differences (with 95% CI) using the random effects model. MAIN RESULTS Fourteen trials compared escitalopram with another SSRI and eight compared escitalopram with a newer antidepressive agent (venlafaxine, bupropion and duloxetine). Escitalopram was shown to be significantly more effective than citalopram in achieving acute response (OR 0.67, 95% CI 0.50 to 0.87). Escitalopram was also more effective than citalopram in terms of remission (OR 0.53, 95% CI 0.30 to 0.93). Significantly fewer patients allocated to escitalopram withdrew from trials compared with patients allocated to duloxetine, for discontinuation due to any cause (OR 0.62, 95% CI 0.38 to 0.99). AUTHORS' CONCLUSIONS Some statistically significant differences favouring escitalopram over other antidepressive agents for the acute phase treatment of major depression were found, in terms of efficacy (citalopram and fluoxetine) and acceptability (duloxetine). There is insufficient evidence to detect a difference between escitalopram and other antidepressants in early response to treatment (after two weeks of treatment). Cost-effectiveness information is also needed in the field of antidepressant trials. Furthermore, as with most standard systematic reviews, the findings rely on evidence from direct comparisons. The potential for overestimation of treatment effect due to sponsorship bias should also be borne in mind.
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Affiliation(s)
- Andrea Cipriani
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Policlinico "G.B.Rossi", Piazzale L.A. Scuro, 10, Verona, Italy, 37134.
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Stepped care treatment of postpartum depression: a primary care-based management model. Womens Health Issues 2008; 18:44-52. [PMID: 18215764 DOI: 10.1016/j.whi.2007.09.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 09/24/2007] [Accepted: 09/25/2007] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Postpartum depression (PPD), the most prevalent serious postpartum complication, is a devastating illness that negatively impacts not only the mother, but also her infant, other family members, and work performance. There is an extensive body of research addressing systems-based quality improvement efforts for treatment of depression in primary care populations; however, little of this research has been directed toward postpartum populations. This paper presents a health care systems-based quality improvement model for the treatment of PPD derived from research outcomes in general primary care populations. METHODS OVID/MEDLINE and PsychINFO searches were performed using the following terms: depression, postpartum depression, mass screening, collaborative care, stepped care, psychotherapy, cognitive-behavioral therapy, interpersonal therapy, and education as keywords. MAIN FINDINGS The PPD management model described herein includes screening and diagnosis, initiation of active treatment, and use of collaborative care, which includes primary care visits, case manager follow-up, and more intensive care, through specialty consultation or referral, for complicated or difficult cases. CONCLUSION Stepped care, a form of collaborative depression treatment, is proposed as a practical, cost-effective method for improving PPD diagnosis and clinical outcomes.
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Cipriani A, Signoretti A, Furukawa TA, Churchill R, Tomelleri S, Omori IM, McGuire H, Barbui C. Venlafaxine versus other anti-depressive agents for depression. Cochrane Database Syst Rev 2007:CD006530. [PMID: 25267891 PMCID: PMC4176661 DOI: 10.1002/14651858.cd006530] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the efficacy of venlafaxine in comparison with other anti-depressive agents in alleviating the acute symptoms of major depressive disorder.To review acceptability of treatment with venlafaxine in comparison with other anti-depressive agents.To investigate the adverse effects of venlafaxine in comparison with other anti-depressive agents.
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Affiliation(s)
- Andrea Cipriani
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
| | - Alessandra Signoretti
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
| | - Toshi A Furukawa
- Department of Psychiatry & Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Rachel Churchill
- Academic Unit of Psychiatry, Community Based Medicine, University of Bristol, Bristol, UK
| | - Silva Tomelleri
- Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Verona, Italy
| | - Ichiro M Omori
- Cochrane Schizophrenia Group, University of Nottingham, Nottingham, UK
| | - Hugh McGuire
- National Coordinating Centre for Women and Child Health, London, UK
| | - Corrado Barbui
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
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Cipriani A, Furukawa TA, Veronese A, Watanabe N, Churchill R, McGuire H, Barbui C. Paroxetine versus other anti-depressive agents for depression. Cochrane Database Syst Rev 2007:CD006531. [PMID: 25267892 PMCID: PMC4176672 DOI: 10.1002/14651858.cd006531] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the efficacy of paroxetine in comparison with other anti-depressive agents in alleviating the acute symptoms of major depressive disorder.To review acceptability of treatment with paroxetine in comparison with other anti-depressive agents.To investigate the adverse effects of paroxetine in comparison with other anti-depressive agents.
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Affiliation(s)
- Andrea Cipriani
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
| | - Toshi A Furukawa
- Department of Psychiatry & Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Antonio Veronese
- Section of Evidence Based Mental Health, Health Service & Population Research Department, Institute of Psychiatry, King’s College London, London, UK
| | - Norio Watanabe
- Department of Psychiatry & Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Rachel Churchill
- Academic Unit of Psychiatry, Community Based Medicine, University of Bristol, Bristol, UK
| | - Hugh McGuire
- National Coordinating Centre for Women and Child Health, London, UK
| | - Corrado Barbui
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
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Cipriani A, Smith KA, Burgess SSA, Carney SM, Goodwin G, Geddes J. Lithium versus antidepressants in the long-term treatment of unipolar affective disorder. Cochrane Database Syst Rev 2006; 2006:CD003492. [PMID: 17054174 PMCID: PMC7003995 DOI: 10.1002/14651858.cd003492.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The main rationale for the use of lithium in the long-term treatment of unipolar affective disorder is its efficacy in treating bipolar affective disorder and resistant depression. However, there is considerable uncertainty about which pharmacological intervention is most effective in the long-term treatment of recurrent unipolar affective disorder. OBJECTIVES To assess the effects of lithium versus antidepressants for the long-term treatment of recurrent affective disorder. SEARCH STRATEGY We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) on 2/9/2005. Reference lists of relevant papers and major textbooks of affective disorder were checked. Experts in the field and pharmaceutical companies were contacted regarding unpublished material. SELECTION CRITERIA Randomised controlled trials comparing lithium against antidepressant medication for the long-term treatment of patients with a diagnosis of affective disorder. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials. MAIN RESULTS Eight trials involving 475 people were included. Two of the studies included a mixed group of participants with either bipolar or unipolar disorder. Relapse was defined as admission to hospital and when all kinds of relapses were considered (both depressive and manic), there was a statistically significant difference in favour of lithium (relative risk (RR) fixed effect 0.34, 95% CI 0.14 to 0.82). The results did not exclude the point of no effect, when the random-effects model was used (RR random effects 0.40, 95% CI 0.14 to 1.18). There were no other statistically significant differences between lithium and antidepressants according to all other outcomes considered. Manic or depressive relapse was defined as prescription of non-study medication for mood disorder, manic or depressive relapse (as defined by the study authors), quality of life, social functioning, occupational functioning, overall drop-out rate, drop-out rate due to side-effects, troublesome side-effects, mortality due to all causes and specifically suicides. AUTHORS' CONCLUSIONS There was adequate efficacy evidence for lithium or antidepressants preventing relapse in unipolar affective disorder, however their relative efficacy was unknown. When considering lithium or antidepressant long-term therapy, patients and clinicians should take into account the patient's clinical history, the side-effects and the individual's likely adherence to the recommended treatment regime. Large-scale, long-term randomised trials in unselected groups of subjects with unipolar affective disorder are needed.
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Affiliation(s)
- Andrea Cipriani
- University of VeronaDepartment of Medicine and Public Health, Section of Psychiatry and Clinical PsychologyPoliclinico "G.B.Rossi"Piazzale L.A. Scuro, 10VeronaItaly37134
| | - Katharine A Smith
- Oxfordshire Mental Health Care NHS TrustDepartment of Old Age PsychiatryOxfordUK
| | - Sally SA Burgess
- Oxfordshire Mental Health Care NHS TrustDepartment of Old Age PsychiatryOxfordUK
| | - Stuart M Carney
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordOxonUKOX3 7JX
| | - Guy Goodwin
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordOxonUKOX3 7JX
| | - John Geddes
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordOxonUKOX3 7JX
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Shearer S, Gordon L. The patient with excessive worry. S Afr Fam Pract (2004) 2006. [DOI: 10.1080/20786204.2006.10873462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Fergusson D, Doucette S, Glass KC, Shapiro S, Healy D, Hebert P, Hutton B. Association between suicide attempts and selective serotonin reuptake inhibitors: systematic review of randomised controlled trials. BMJ 2005; 330:396. [PMID: 15718539 PMCID: PMC549110 DOI: 10.1136/bmj.330.7488.396] [Citation(s) in RCA: 300] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2005] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To establish whether an association exists between use of selective serotonin reuptake inhibitors (SSRIs) and suicide attempts. DESIGN Systematic review of randomised controlled trials. DATA SOURCES Medline and the Cochrane Collaboration's register of controlled trials (November 2004) for trials produced by the Cochrane depression, anxiety, and neurosis group. SELECTION OF STUDIES Studies had to be randomised controlled trials comparing an SSRI with either placebo or an active non-SSRI control. We included clinical trials that evaluated SSRIs for any clinical condition. We excluded abstracts, crossover trials, and all trials whose follow up was less than one week. RESULTS Seven hundred and two trials met our inclusion criteria. A significant increase in the odds of suicide attempts (odds ratio 2.28, 95% confidence 1.14 to 4.55, number needed to treat to harm 684) was observed for patients receiving SSRIs compared with placebo. An increase in the odds ratio of suicide attempts was also observed in comparing SSRIs with therapeutic interventions other than tricyclic antidepressants (1.94, 1.06 to 3.57, 239). In the pooled analysis of SSRIs versus tricyclic antidepressants, we did not detect a difference in the odds ratio of suicide attempts (0.88, 0.54 to 1.42). DISCUSSION Our systematic review, which included a total of 87 650 patients, documented an association between suicide attempts and the use of SSRIs. We also observed several major methodological limitations in the published trials. A more accurate estimation of risks of suicide could be garnered from investigators fully disclosing all events.
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Affiliation(s)
- Dean Fergusson
- Ottawa Health Research Institute, Clinical Epidemiology Program, 501 Smyth Road, Box 201, Ottawa, Ontario, Canada K1H 8L6.
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Sullivan PW, Valuck R, Saseen J, MacFall HM. A comparison of the direct costs and cost effectiveness of serotonin reuptake inhibitors and associated adverse drug reactions. CNS Drugs 2005; 18:911-32. [PMID: 15521793 DOI: 10.2165/00023210-200418130-00006] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND The economic burden of depression is known to be high and was estimated to be USD 83.1 billion in 2000. Serotonin reuptake inhibitors (SRIs), including both selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs), have a superior adverse effect and safety profile relative to traditional agents (e.g. TCAs), and as a result have demonstrated superior cost effectiveness. Although efficacy across the SRIs is similar, the incidence of adverse drug reactions (ADRs) within SRIs remains significant and varies by agent. Patients who experience ADRs from SRIs may seek medical care, require additional treatment, and even discontinue treatment altogether, leading to increased utilisation and cost of therapy. OBJECTIVE This study estimates the direct cost and cost effectiveness, taking into account the impact of treatment-related ADRs, of eight currently marketed SRIs (citalopram, escitalopram, generic fluoxetine, paroxetine, paroxetine controlled release [CR], sertraline, venlafaxine and venlafaxine extended release [XR]) used as initial treatment for depression. METHODS A decision analytic model with a 6-month treatment goal was used to estimate the direct cost and cost effectiveness of treatment from the managed care/payer perspective. Estimates of SRI-related ADRs, associated treatments and costs were derived from the US FDA-approved prescribing information and published literature. Efficacy was assumed to be similar across all SRIs. Effectiveness was measured using quality-adjusted life years (QALY) based on EuroQol EQ-5D scores derived from the 2000 Medical Expenditure Panel Survey (MEPS). Censored least absolute deviations (CLAD) regression analysis was used to derive age-adjusted estimates of utility for all health states. Univariate and Bayesian second-order multivariate probabilistic sensitivity analyses were conducted to examine the impact of uncertainty in the parameter estimates. RESULTS The expected direct cost and cost effectiveness of treatment from least to most expensive were: escitalopram (USD 3891; 0.341), citalopram (USD 3938; 0.340), generic fluoxetine (USD 4034; 0.335), venlafaxine XR (USD 4226; 0.336), sertraline (USD 4250; 0.335), generic paroxetine (USD 4385; 0.332), paroxetine CR (USD 4440; 0.332) and venlafaxine (USD 4613; 0.326). Monte Carlo simulation results suggested that escitalopram was the most likely (77%) to be cost effective for a willingness to pay < or = USD 50,000 per QALY, followed by citalopram (22%), generic fluoxetine (0.3%) and all other SRIs (0%). Sensitivity analyses indicated that the results of the study were robust to the assumptions underpinning the model. CONCLUSIONS SRI-related ADRs have a significant impact on the direct cost and cost effectiveness of treatment. Escitalopram, with the lowest ADR rate of the SRIs, had the lowest expected treatment cost and greatest effectiveness when compared with citalopram, generic fluoxetine, generic paroxetine, paroxetine CR, sertraline, venlafaxine and venlafaxine XR.
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Affiliation(s)
- Patrick W Sullivan
- Pharmaceutical Outcomes Research Program, Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA.
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Stahl SM, Pradko JF, Haight BR, Modell JG, Rockett CB, Learned-Coughlin S. A Review of the Neuropharmacology of Bupropion, a Dual Norepinephrine and Dopamine Reuptake Inhibitor. Prim Care Companion CNS Disord 2004; 6:159-166. [PMID: 15361919 PMCID: PMC514842 DOI: 10.4088/pcc.v06n0403] [Citation(s) in RCA: 296] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2003] [Accepted: 05/27/2004] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND: The neurochemical and biological effects of antidepressant medications have become better defined over the last decade. When the anti-depressant bupropion was introduced in the United States in 1989, the specific pharmacologic basis of its clinical effects was uncertain. Research conducted over the past decade has significantly advanced the understanding of the neuropharmacology of bupropion and has demonstrated a novel mechanism of antidepressant activity. This article discusses the mechanism of action of bupropion and relates the drug's neuropharmacologic effects to its clinical efficacy and tolerability profiles. DATA SOURCES: Data were obtained via the MEDLINE database in an English-language search spanning the period 1965 to May 2002 and using the search terms bupropion, bupropion SR, and antidepressants, as well as from the manufacturer's bupropion databases. CONCLUSIONS: The preclinical and clinical data show that bupropion acts via dual inhibition of norepinephrine and dopamine reuptake and is devoid of clinically significant serotonergic effects or direct effects on postsynaptic receptors. Dual norepinephrine and dopamine reuptake inhibition is associated with a unique clinical profile. Bupropion has demonstrated efficacy comparable to that of other antidepressants. However, because bupropion is a selective norepinephrine and dopamine reuptake inhibitor with no serotonergic activity, common antidepressant-associated side effects, such as sexual dysfunction, weight gain, and sedation, are not associated with bupropion therapy.
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Affiliation(s)
- Stephen M. Stahl
- Neuroscience Education Institute, University of California, San Diego; Bay Pointe Depression Clinic, New Baltimore, the Department of Family Practice, Mt. Clemens General Hospital, Mt. Clemens, and St. John Hospital, Detroit, Mich.; and GlaxoSmithKline, Research Triangle Park, N.C
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