Guidelines for treating depressive illness with antidepressants: A statement from the British Association for Psychopharmacology

The Korean Medication Algorithm Project for Depressive Disorder 2021: Comparisons with Other Treatment Guidelines

The Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) first was published in 2002, and has been revised four times, in 2006, 2012, 2017, and 2021. In this review, we compared recommendations from the recently revised KMAP-DD 2021 to four global clinical practice guidelines (CPGs) for depression published after 2010. The recommendations from the KMAP-DD 2021 were similar to those from other CPGs, although there were some differences. The KMAP-DD 2021 reflected social culture and the healthcare system in Korea and recent evidence about pharmacotherapy for depression, as did other recently published evidence-based guidelines. Despite some intrinsic limitations as an expert consensus-based guideline, the KMAP-DD 2021 can be helpful for Korean psychiatrists making decisions in clinical settings by complementing previously published evidence-based guidelines, especially for some clinical situations lacking evidence from rigorously designed clinical trials.

Antidepressant prescriptions have not fully reflected evolving evidence from cumulative network meta-analyses and guideline recommendations

OBJECTIVES

This study compares three major elements of evidence-based medicine (EBM) practices, namely evidence synthesis, clinical practice guidelines (CPGs), and real-world prescriptions in the United States, regarding antidepressant treatments of major depression over the past 3 decades.

STUDY DESIGN AND SETTING

We conducted network meta-analyses (NMAs) of antidepressants every 5 years up to 2016 based on a comprehensive data set of double-blind randomized controlled trials. We identified CPGs and extracted their recommendations. We surveyed the prescriptions in the United States at 5-year intervals up to 2015.

RESULTS

Most drugs recommended by CPGs presented favorable performance in efficacy and acceptability in NMAs. However, CPG recommendations were often in terms of drug classes rather than individual drugs, whereas NMAs suggested distinctive difference between drugs within the same class. The update intervals of all CPGs were longer than 5 years. All the antidepressants prescribed frequently in the United States were recommended by CPGs. However, changes in prescriptions did not correspond to alterations in CPGs or to apparent changes in the effects indicated by NMAs. Many factors including marketing efforts, regulations, or patient values may have played a role.

CONCLUSION

Enhancements including accelerating CPG updates and monitoring the impact of marketing on prescriptions should be considered in future EBM implementation.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update

This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.

Evidence synthesis, practice guidelines and real-world prescriptions of new generation antidepressants in the treatment of depression: a protocol for cumulative network meta-analyses and meta-epidemiological study

INTRODUCTION

Depressive disorders are the most common, burdensome and costly mental disorders. Their treatments have developed through the past decades and we now have more than a dozen new generation antidepressants, while a series of guidelines have been published to provide recommendations over the years. However, there still may exist important gaps in this evidence synthesis and implementation process. Systematic reviews may not have been conducted in the most unbiased, informative and timely manners; guidelines may not have reflected the most up-to-date evidence; clinicians may not have changed their clinical decision-makings in accordance with the relevant evidence. The aim of this study is to examine the gaps between the ideally synthesised evidence, guideline recommendations and real-world clinical practices in the prescription of new generation antidepressants for major depression through the past three decades.

METHODS AND ANALYSIS

We will conduct cumulative network meta-analyses (cNMAs) based on the comprehensive systematic review which has identified published and unpublished head-to-head randomised controlled trials comparing the following antidepressants in the acute phase treatment of major depression: agomelatine, amitriptyline, bupropion, citalopram, clomipramine, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nefazodone, paroxetine, reboxetine, sertraline, trazodone, venlafaxine, vilazodone and vortioxetine. The primary outcomes will be the proportions of patients who responded (efficacy) and who withdrew from treatment for any reasons (acceptability). We will conduct a random effects cNMA to synthesise evidence and obtain a comprehensive ranking of all new generation antidepressants based on their surface under the cumulative ranking curves. We will identify series of international clinical practice guidelines for the treatment of major depression of adults and summarise their recommendations. We will estimate real-world prescription patterns of antidepressants in the nationally representative samples in USA in the Medical Expenditure Panel Survey. We will compare and evaluate the gaps between the rankings according to cNMAs conducted at 5-year intervals between 1990 and 2015, recommendations in guidelines published in the ensuing 5 years and actual practices thereafter.

ETHICS AND DISSEMINATION

This review does not require ethical approval. We will disseminate our findings through publications in peer-reviewed journals and presentations at conferences.

TRIAL REGISTRATION NUMBER

UMIN000031898.

La valutazione dei costi del trattamento farmacologico nella depressione. Una revisione critica della letteratura

Aims -. To review the factors which are relevant for a correct evaluation of the costs of antidepressant drug treatment and to report the results of the studies on the efficacy, tollerability and costs of the most utilized antidepressants (tricyclics and SSRI). Methods - We reviewed the international literature concerning both with comparative studies on efficacy, tollerability and safety of tricyclics and SSRI and with studies of pharmacoeconomics that have focused on the costs of depression and of different antidepressant treatments. Results - Depression involves high costs, especially if indirect costs are considered. Comparative studies indicate a substantial equivalence of efficacy between tricyclics and SSRI, but a better tolerability of the latters. The few studies of pharmacoeconomics that have evaluated different antidepressant drugs indicate that a treatment with SSRI involves lower costs as compared with tricyclics. These results are due to the higher indirect costs (compliance, drop-out for side-effects, work loss, etc.) of tricyclics. Conclusions - A correct economic evaluation of an antidepressant drug treatment should consider both direct and indirect costs. Available studies indicate that SSRI involves lower costs as compared with tricyclics; however in order to confirm these results more studies of pharmacoeconomics are needed with experimental designes (longitudinal studies) taking into account the outcome of patients treated in routine clinical practice.

Adverse effects from antidepressant treatment: randomised controlled trial of 601 depressed individuals

RATIONALE

Premature discontinuation of antidepressant drugs is a frequent clinical problem. Adverse effects are common, occur early on in treatment and are reported to be one of the main reasons for discontinuation of antidepressant treatment.

OBJECTIVES

To investigate the association between adverse effects occurring in the first 2 weeks of antidepressant treatment and discontinuation by 6 weeks as the outcome. To investigate the time profile of adverse effects induced by the selective serotonin reuptake inhibitor citalopram and the noradrenaline reuptake inhibitor reboxetine over 12 weeks of treatment.

METHODS

Six hundred and one depressed individuals were randomly allocated to either citalopram (20 mg daily) or reboxetine (4 mg twice daily). A modified version of the Toronto Side Effects Scale was used to measure 14 physical symptoms at baseline (medication free) and at 2, 6 and 12 weeks after randomisation.

RESULTS

Individuals randomised to reboxetine reported a greater number of adverse effects and were more likely to stop treatment than individuals receiving citalopram. Dizziness (OR 1.83; 95% CI 1.09, 3.09; p = 0.02) and the total number of adverse effects (OR 1.12; 95% CI 1.00, 1.25; p = 0.06) reported at 2 weeks were associated with discontinuation from overall antidepressant treatment by 6 weeks. Reports of adverse effects tended to reduce throughout the 12 weeks for both antidepressants.

CONCLUSIONS

The majority of adverse effects were not individually associated with discontinuation from antidepressant treatment. Reports of physical symptoms tended to reduce over time. The physical symptoms that did not reduce over time may represent symptoms of depression rather than antidepressant-induced adverse effects.

What is the association between quality of treatment for depression and patient outcomes? A cohort study of adults consulting in primary care

BACKGROUND

The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The main objective of this study was to examine the association between receiving at least one minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6- and 12-months. Associations with receiving pharmacotherapy and/or psychotherapy and the role of severity of depression were examined.

METHODS

This cohort study included 908 adults meeting criteria for previous-year MDE and consulting at one of 65 primary care clinics in Quebec, Canada. Multilevel analyses were performed.

RESULTS

Results show that (i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; (ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and (iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months.

LIMITATIONS

Measures are self-reported. Participants were recruited at different stages over the course of their MDE.

CONCLUSIONS

This study shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions, but that those with more severe depressive symptoms are more likely to receive adequate treatment and improve across time.

Systematic review and meta-analysis of serotonin transporter genotype and discontinuation from antidepressant treatment

There is evidence that 5-HTTLPR is associated with response following treatment from selective serotonin reuptake inhibitors (SSRIs). The short (S) allele has reduced serotonin transporter expression, compared to the long (L) allele, and has been reported to be associated with poorer response in Europeans, with the effect in other populations unclear. However the published literature is inconsistent. A systematic review and meta-analysis was performed to investigate the effect of 5-HTTLPR on discontinuation from antidepressant treatment. Data were obtained from 17 studies including 4309 participants. The principal outcome measure was the allelic odds ratio (OR) for the 5-HTTLPR S allele and discontinuation status. A random effects meta-analysis provided no evidence that the S allele was associated with increased odds of discontinuation from SSRIs in Europeans (OR 1.09, 95% CI 0.83-1.42, p=0.53; 10 studies, n=2504) but in East Asians there was evidence of a reduced odds of discontinuation (OR 0.28, 95% CI 0.12-0.64, p=0.002; 2 studies, n=136). There was a suggestion of small study bias (p=0.05). This meta-analysis provides no evidence of an association between 5-HTTLPR and discontinuation from antidepressant treatment in Europeans. The low number of studies in East Asian samples using SSRIs reduces confidence in our evidence that the S allele decreases the odds of discontinuation in this population. At present, there is no evidence of an association between 5-HTTLPR and discontinuation from SSRI treatment in a European population with further studies required to investigate its effects in different populations.

Selective serotonin reuptake inhibitor use in primary care: a 5-year naturalistic study

OBJECTIVE

To investigate prescribing trends of selective serotonin reuptake inhibitors (SSRIs) during the course of the Defeat Depression Campaign (1992 to 1996).

METHODS

This study utilised cross-sectional data on the prescribing of SSRIs for the treatment of depression from a large primary care database for the 5 consecutive years of the Defeat Depression Campaign, producing the largest study of SSRI use to date.

RESULTS

A total of 93 600 prescriptions were issued for fluoxetine, paroxetine and sertraline, in 27 210 treatment episodes. Over the 5-year period, there was a five-fold increase in the number of prescriptions issued, and a four-fold increase in the number of patients treated, reflecting a trend for longer periods of treatment. Patients initiating treatment with fluoxetine were most likely and those initiating treatment with sertraline were least likely to complete 60, 90 and 120 consecutive days of treatment. Differences in dose patterns also emerged and were consistent throughout the study. Fluoxetine-treated patients were most likely to remain on the starting dose of 20mg daily, while large numbers of sertraline-treated patients received doses above the recommended dose of 50mg daily. These differences were not apparent from clinical trials, and this may be an artefact of trial design.

CONCLUSION

Differences in the doses prescribed may explain why sertraline-treated patients are less likely to complete an adequate course of antidepressant therapy. Longitudinal studies are required to evaluate fully the clinical significance of these findings.

Quality of care for major depression and its determinants: a multilevel analysis

BACKGROUND

Numerous studies highlight an important gap in the quality of care for depression in primary care. However, basic indicators were often used. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The purpose of this study was to estimate the proportion of primary care patients with a major depressive episode (MDE) who receive adequate treatment and to examine the individual and organizational (i.e., clinic-level) characteristics associated with the receipt of at least one minimally adequate treatment for depression.

METHODS

The sample used for this study included 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for MDE during the 12 months preceding the survey (T1), and nested within 65 primary care clinics. Data reported in this study were obtained from the "Dialogue" project. Adherence rates for 27 quality indicators selected to cover the most important components of depression treatment were estimated. Multilevel analyses were conducted.

RESULTS

Adherence to guidelines was high (>75%) for one third of the quality indicators that were measured but was low (<60%) for nearly half of the measures. Just over half of the sample (52.2%) received at least one minimally adequate treatment for depression. At the individual level, determinants of receipt of minimally adequate care included age, having a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and the severity of depression. At the clinic level, determinants included the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration.

CONCLUSIONS

Our findings suggest that interventions are needed to increase the extent to which primary mental health care conforms to evidence-based recommendations. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders

Sleep disorders are common in the general population and even more so in clinical practice, yet are relatively poorly understood by doctors and other health care practitioners. These British Association for Psychopharmacology guidelines are designed to address this problem by providing an accessible up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. A consensus meeting was held in London in May 2009. Those invited to attend included BAP members, representative clinicians with a strong interest in sleep disorders and recognized experts and advocates in the field, including a representative from mainland Europe and the USA. Presenters were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomized controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aimed to reach consensus where the evidence and/or clinical experience was considered adequate or otherwise to flag the area as a direction for future research. A draft of the proceedings was then circulated to all participants for comment. Key subsequent publications were added by the writer and speakers at draft stage. All comments were incorporated as far as possible in the final document, which represents the views of all participants although the authors take final responsibility for the document.

Protocol for the THREAD (THREshold for AntiDepressants) study: a randomised controlled trial to determine the clinical and cost-effectiveness of antidepressants plus supportive care, versus supportive care alone, for mild to moderate depression in UK general practice

Background

Depression guidelines in the UK recommended a policy of watchful waiting for mild depression due to a lack of evidence for the effectiveness of antidepressant treatment for mild cases. However there has been relatively little research carried out in primary care to help establish the severity threshold at which antidepressant treatment is effective and cost-effective.

Methods/Design

The THREAD (THREshold for AntiDepressants) study is a multi-centre randomised controlled trial designed to determine the clinical and cost effectiveness of a selective serotonin reuptake inhibitor (SSRI) plus general practitioner (GP) supportive care, versus supportive care alone, for mild to moderate depression in primary care. The aim is to recruit 300 patients from three centres (Southampton, London and Liverpool). Depressive symptoms will be assessed at baseline, 12 weeks and 26 weeks, using the 17-item Hamilton Depression Rating Scale (HDRS). Two severity sub-groups of patients will be recruited, with HDRS scores of 12–15, and 16–19. Possible predictors of response will be explored including life events and difficulties and alcohol consumption. Analysis of covariance, controlling for baseline value, severity group and centre will be used to estimate the overall treatment effectiveness (difference in HDRS score) at final follow up. The primary analysis will be by 'intention to treat' using double sided tests. The interaction between severity sub-group and treatment will be tested, and if appropriate, effects within separate severity sub-groups estimated. The economic analysis will compare the two treatment groups in terms of mean costs and cost-effectiveness.

Discussion

The results of this study will give GPs important information to help them determine the severity of depression at which antidepressant treatment is likely to be cost-effective.

Evidence-based guidelines for management of attention-deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology

Attention-deficit/hyperactivity disorder (ADHD) is an established diagnosis in children, associated with a large body of evidence on the benefits of treatment. Adolescents with ADHD are now leaving children's services often with no readily identifiable adult service to support them, which presents problems as local pharmacy regulations often preclude the prescription of stimulant drugs by general practitioners (GPs). In addition, adults with ADHD symptoms are now starting to present to primary care and psychiatry services requesting assessment and treatment. For these reasons, the British Association for Psychopharmacology (BAP) thought it timely to hold a consensus conference to review the body of evidence on childhood ADHD and the growing literature on ADHD in older age groups. Much of this initial guidance on managing ADHD in adolescents in transition and in adults is based on expert opinion derived from childhood evidence. We hope that, by the time these guidelines are updated, much evidence will be available to address the many directions for future research that are detailed here.

Clinical practice with anti-dementia drugs: a consensus statement from British Association for Psychopharmacology

The British Association for Psychopharmacology (BAP) coordinated a meeting of experts to review the evidence on the drug treatment for dementia. The level of evidence (types) was rated using a standard system: Types 1a and 1b (evidence from meta-analysis of randomised controlled trials or at least one controlled trial respectively); types 2a and 2b (one well-designed study or one other type of quasi experimental study respectively); type 3 (non-experimental descriptive studies); and type 4 (expert opinion). There is type 1a evidence for cholinesterase inhibitors (donepezil, rivastigmine and galantamine) for mild to moderate Alzheimer's disease; memantine for moderate to severe Alzheimer's disease; and for the use of bright light therapy and aromatherapy. There is type 1a evidence of no effect of anti inflammatory drugs or statins. There is conflicting evidence regarding oestrogens, with type 2a evidence of a protective effect of oestrogens but 1b evidence of a harmful effect. Type 1a evidence for any effect of B12 and folate will be forthcoming when current trials report. There is type 1b evidence for gingko biloba in producing a modest benefit of cognitive function; cholinesterase inhibitors for the treatment of people with Lewy body disease (particularly neuropsychiatric symptoms); cholinesterase inhibitors and memantine in treatment cognitive impairment associated with vascular dementia; and the effect of metal collating agents (although these should not be prescribed until more data on safety and efficacy are available). There is type 1b evidence to show that neither cholinesterase inhibitors nor vitamin E reduce the risk of developing Alzheimer's disease in people with mild cognitive impairment; and there is no evidence that there is any intervention that can prevent the onset of dementia. There is type 1b evidence for the beneficial effects of adding memantine to cholinesterase inhibitors, and type 2b evidence of positive switching outcomes from one cholinesterase inhibitor to another. There is type 2a evidence for a positive effect of reminiscence therapy, and type 2a evidence that cognitive training does not work. There is type 3 evidence to support the use of psychological interventions in dementia. There is type 2 evidence that a clinical diagnosis of dementia can be made accurately and that brain imaging increases that accuracy. Although the consensus statement dealt largely with medication, the role of dementia care in secondary services (geriatric medicine and old age psychiatry) and primary care, along with health economics, was discussed. There is ample evidence that there are effective treatments for people with dementia, and Alzheimer's disease in particular. Patients, their carers, and clinicians deserve to be optimistic in a field which often attracts therapeutic nihilism.

Why do we need new and better antidepressants?

The range of available antidepressants is reviewed in relation to mechanisms of action and the evidence of efficacy in general and efficacy in severe depression in particular. In studies investigating efficacy in major depressive disorder, not all antidepressants have been shown to have clear-cut efficacy in severe depression. Here, the minimum standards for the necessary methodology to investigate efficacy in severe depression are reviewed and the methods that are needed to establish efficacy as a superior antidepressant or as an antidepressant with a faster than expected response are suggested. A review of the mechanisms of action of different antidepressants is accompanied by a critical review of the properties of an antidepressant likely to achieve either efficacy in severe depression or the status of a superior antidepressant.

Double-blind comparison of fluoxetine and nortriptyline in the treatment of moderate to severe major depression

BACKGROUND

Depression is an international public health problem. Impairment in social and occupational functioning, increased comorbidity with other psychiatric and medical conditions, and an increased risk of mortality are a few of its consequences. Some psychiatrists have the impression that selective serotonin re-uptake inhibitors may not work as well as tricyclic anti-depressants in severe depression and/or melancholia. On the contrary, there is a general belief that selective serotonin re-uptake inhibitors are superior to the tricyclic anti-depressants in having fewer side-effects, particularly cardiovascular effects. The objective of this double-blind study was to compare the efficacy and safety of fluoxetine and nortriptyline in patients with moderate to severe major depression.

METHODS

A total of 48 adult outpatients who met the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), forth edition for major depression, based on the structured clinical interview for DSM IV participated in the trial. Patients had a baseline Hamilton Rating Scale for Depression score of at least 20. In this double-blind, single-center trial, patients were randomly assigned to receive nortriptyline 150 mg/day (group 1) or fluoxetine 60 mg/day (group 2) for 6-weeks. The outcome of the two groups was assessed using Hamilton Depression Rating Scale, a side-effect checklist and a regular ECG assessment.

RESULTS

The results suggest that the efficacy of nortriptyline is superior to fluoxetine in this group of major depressed patients. No significant differences were observed between dropout rates in the two groups but anti-cholinergic side-effects were significantly more frequent with nortriptyline than with fluoxetine but there was no significant difference in cardiovascular effects in particular QTc prolongation.

CONCLUSION

The results of the current study suggest that nortriptyline was more effective than fluoxetine in the treatment of moderate to severe depression. A larger study is warranted.

Comparison of Lavandula angustifolia Mill. tincture and imipramine in the treatment of mild to moderate depression: a double-blind, randomized trial

Depression is a major health problem and is not only underrecognized and undertreated but is associated with significant morbidity and mortality. Lavandula angustifolia Mill. (Lamiacae) is used to treat depression. Many medicinal plant textbooks refer to this indication, whereas there is no evidence-based document. Our objective was to compare the efficacy of tincture of L. angustifolia with imipramine in the treatment of mild to moderate depression and to evaluate the possible adjuvant effect of this tincture in a 4 week double-blind, randomized trial. Forty-five adult outpatients who met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, for major depression based on the structured clinical interview for DSM IV participated in the trial. Patients have a baseline Hamilton Rating Scale for Depression score of at least 18. In this double-blind, single-center trial, patients were randomly assigned to receive lavandula tincture (1:5 in 50% alcohol ) 60 drops/day plus placebo tablet (Group A), tablet imipramine 100 mg/day plus placebo drop (Group B) and tablet imipramine 100 mg/day plus lavandula tincture 60 drops/day (Group C) for a 4-week study. In this small preliminary double-blind and randomized trial, lavandula tincture at this concentration was found to be less effective than imipramine in the treatment of mild to moderate depression (F=13.16, df=1, P=.001). In the imipramine group, anticholinergic effects such as dry mouth and urinary retention were observed more often that was predictable, whereas headache was observed more in the lavandula tincture group. A combination of imipramine and lavandula tincture was more effective than imipramine alone (F=20.83, df=1, P<.0001). As this study indicates, one of the advantages of this combination is a better and earlier improvement. The main overall finding from this study is that lavandula tincture may be of therapeutic benefit in the management of mild to moderate depression as adjuvant therapy. A large-scale trial is justified.

Antidepressant use in clinical practice: efficacy v. effectiveness

BACKGROUND

Although the efficacy of antidepressants has been demonstrated in randomised, controlled clinical trials, it is how an antidepressant is used in clinical practice that determines its clinical effectiveness, or real-world efficacy.

AIMS

To explore the frequency with which antidepressants are used at adequate dose and duration to obtain remission of symptoms and prevent relapse in clinical practice and discuss potential implications for clinical outcomes.

METHOD

Studies of antidepressant prescribing were reviewed and comparisons made between antidepressant classes and individual compounds within those classes.

RESULTS

Naturalistic studies show that patients who begin therapy on tricyclic antidepressants often receive sub-therapeutic doses for inadequate duration; conversely, patients who begin therapy on selective serotonin reuptake inhibitors more often receive an adequate dose of therapy for a longer duration. CONCLUSIONS; How antidepressants are used in clinical practice can determine the clinical outcomes that are achieved. Antidepressants that are more forgiving of sub-optimal prescribing and use patterns by providers and patients, respectively, may help to improve real-world efficacy.

Optimising antidepressant use in clinical practice: towards criteria for antidepressant selection

BACKGROUND

Current treatment for depression in primary care and other out-patient settings demonstrates a pattern that is incongruous with the magnitude of the burden of depression suggested by its associated disability.

AIMS

To review important considerations in current depression treatment with a focus on antidepressant use.

METHOD

Factors influencing the undertreatment of depression in real-world settings are examined.

RESULTS

Patient and clinician behaviour as well as the incentives created by the health care system affect the likelihood of realising effective antidepressant therapy in practice.

CONCLUSIONS

Given the complexities of clinical practice, selection criteria for an antidepressant should include safety, efficacy and tolerability, as well as the ability of the antidepressant to deliver real-world efficacy while balancing health care costs in the long term.

Assessment of clinical guidelines for continuation treatment in major depression

OBJECTIVE

The primary objective of this study was to assess the appropriateness of the existing Dutch clinical guidelines for the treatment of depression from a health-economic perspective. The existing guidelines recommend continuation treatment for a period up to 9 months.

METHODS

The assessment was based on a Markov model using decision-analytic techniques. For this analysis we defined six mutually exclusive states defined by the existence of depression and type of treatment. The outcomes for the model were defined as: time without depression (TWD), quality-adjusted life years (QALYs), direct medical costs, and cost of lost productivity. The primary perspective of the study was that of the third-party payer, while the secondary perspective was that of the society in 1999. The probabilities of clinical events and therapeutic choices as well as the utilities were based on published literature. The medical resource use related to each state was abstracted from published literature and expert opinion. The associated 1999 unit costs of the used medical resources were derived from official Dutch tariff lists of allowable reimbursements. Indirect costs in this model were based on lost productivity only.

RESULTS

The results of the primary analysis showed that the use of the guidelines is not cost-effective. Continuation treatment for a period of 9 months increases the total direct medical costs (NLG 1276 vs. NLG 474), decreases the costs resulting from lost productivity (NLG 304 vs. NLG 909), increases total costs (NLG 1580 vs. NLG 1383) and increases TWD (96.9% vs. 86.4%). However, continuation treatment does not change the utility outcomes (0.60 vs. 0.61 QALYs) for both treatment strategies. Hence continuation treatment is not cost-effective from either a third-party payer perspective or a societal perspective. A scenario analysis showed that an extension of the continuation treatment to maintenance treatment might result in a favorable cost-effectiveness outcome of the treatment guideline.

CONCLUSION

In conclusion, based on the assumptions used in the model, the current Dutch treatment guidelines for depression are only appropriate from a health-economic perspective if continuation treatment is extended to maintenance treatment.

Treatment delivery and guidelines in primary care

Because depressive illness is so prevalent, the majority of patients are managed in primary care, without recourse to specialist services. Primary care management is seen to fall short of the standards set in secondary care, but unfortunately there is as yet relatively little evidence from primary care to guide management in this distinctive patient population. Guidelines have been introduced as a means of quality management, and their value in improving care has been assessed in trials. To date, the benefits of the implementation of guidelines have been marginal at best. By contrast, strategies which improve the access of patients to specialist services do seem to be beneficial. There is also evidence that such strategies may be associated with 'cost-offset'. Choice of antidepressant medication for maximum cost benefit should also be informed by an evidence base, which is beginning to be accumulated. Further research on this topic in the primary care context is still needed.

Selective serotonin reuptake inhibitor treatment in the UK: risk of relapse or recurrence of depression

BACKGROUND

Patients with depression are often not prescribed antidepressants for an adequate period of time.

AIMS

The impact of antidepressant prescribing patterns on the risk of relapse or recurrence of depression is examined.

METHOD

The MediPlus UK Primary Care Database was used to identify patients treated for depression with a selective serotonin reuptake inhibitor (SSRI). Records were used to construct hierarchical prescription patterns (less than 120 days, switching/augmentation, upward titration, or stable use) as indicators for the occurrence of relapse or recurrence of depression.

RESULTS

Patients with stable use experienced the lowest risk of relapse or recurrence. Factors significantly associated with increased risk include prior use of anxiolytic medications, more comorbid conditions and younger age.

CONCLUSIONS

The SSRI prescription pattern most consistent with recommended depression treatment guidelines was associated with the lowest risk of relapse or recurrence.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. British Association for Psychopharmacology

A revision of the British Association for Psychopharmacology guidelines for treating depressive disorders with antidepressants was undertaken in order to specify the scope and target of the guidelines and to update the recommendations based explicitly on the available evidence. A consensus meeting, involving experts in depressive disorders and their treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is given which identifies the quality of evidence followed by recommendations, the strength of which are based on the level of evidence. The guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing, management when initial treatment fails, continuation treatment, maintenance treatment to prevent recurrence and stopping treatment.

Pharmacodynamics of milnacipran in young and elderly volunteers

AIMS

To investigate the pharmacodynamics of milnacipran in healthy young and elderly volunteers.

METHODS

Randomized double-blind crossover designs were employed and a standardized psychometric battery was administered pre and post dose for both studies. In the first study 10 healthy young volunteers received milnacipran 12.5 mg, 25 mg, 50 mg, 100 mg as a single dose or matched placebo. The test battery was administered at baseline and at 1, 2, 4 and 6 h post dose. The second study compared the effects of milnacipran 75 mg (50 mg+25 mg) per day, amitriptyline 50 mg (25 mg+25 mg) per day and placebo for 3 days' dosing in healthy volunteers aged over 65 years. The test battery was administered at baseline and at 2, 10 and 24 h post dose. The psychometric battery included critical flicker fusion (CFF), choice reaction time (CRT), compensatory tracking (CTT) and tests of short-term memory (STM), subjective sedation (LARS) and subjective sleep (LSEQ).

RESULTS

Milnacipran produced no significant dose related effects in the young volunteers. For the elderly, milnacipran significantly (P<0.05) raised CFF scores compared with placebo but had no significant effects on any of the other measures used. Amitriptyline, in contrast, significantly (P<0. 05) lowered CFF threshold, lengthened CRT and increased error on the CTT. On the subjective variables, LARS and LSEQ, amitriptyline increased ratings both of sedation and of difficulty in waking from sleep.

CONCLUSIONS

The results showed that milnacipran at single doses of up to 100 mg in healthy young volunteers is free from disruptive effects on cognitive function and psychomotor performance. In addition, milnacipran 75 mg (50+25 mg) appears to be free of negative effects on cognitive function in elderly volunteers, where it seemingly improves performance on CFF. In contrast, the tricyclic antidepressant amitriptyline, used here as a positive internal control, significantly impaired performance in the elderly on the majority of psychometric measures used in this study. This finding not only validated the sensitivity of this current test battery but also indicates the potential behavioural toxicity of amitriptyline in clinical use in the elderly.

Longitudinal patterns of antidepressant prescribing in primary care in the UK: comparison with treatment guidelines

The objective of this study was to determine whether patients beginning therapy on the most common tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) differed in their likelihood of having antidepressant treatment that was consistent with recommended treatment guidelines in the UK. An analytical file constructed from a large general practitioner medical records database (DIN-LINK) from the UK for the years 1992-97 was constructed. A total of 16,204 patients with a new episode of antidepressant therapy who initiated therapy on one of the most often prescribed TCAs (amitriptyline, dothiepin, imipramine and lofepramine) or SSRIs (fluoxetine, paroxetine and sertraline) were analysed. A dichotomous measure was defined to indicate whether subjects were prescribed at least 120 days of antidepressant therapy at an adequate average daily dose within the first 6 months after initiation of therapy. Only 6.0% of patients initiating therapy on aTCA and 32.9% of patients initiating therapy on a SSRI were prescribed antidepressant treatment that was consistent with treatment guidelines. After controlling for observable characteristics, patients who initiated therapy on a SSRI were much more likely (odds ratio=7.473, p<0.001) to have a prescribed average daily dose and duration consistent with recommended treatment guidelines within the first 6 months of initiating therapy than were patients who initiated therapy on a TCA. These findings suggest that initial antidepressant selection is an important determinant of whether the subsequent course of treatment is consistent with current national guidelines for the treatment of depression in the UK.

Fluoxetine and dothiepin therapy in primary care and health resource utilization: Evidence from the United Kingdom

We attempted to evaluate differences in healthcare resource utilization following the initiation of antidepressant therapy with dothiepin or fluoxetine in primary care in the United Kingdom, by means of retrospective analysis of data from the Doctors Independent Network (DIN-LINK) records system, with a two-stage, multiple regression adjusted for potential bias stemming from non-random selection of initial drug choice in clinical practice. We counted patients' use of healthcare resources in the year following initiation of antidepressant therapy. After controlling for both observed and unobserved baseline characteristics correlated with initial drug selection, we found that dothiepin patients would have 0.18 additional non-accident and emergency (ACE) admission, 0.007 more ACE admissions, and 1.09 more general referrals than patients who started therapy with fluoxetine. Fluoxetine patients would have 0.35 more prescriptions for the initial antidepressant. Dothiepin patients would make 5.4 fewer visits to GPs' surgery, have 0.2 fewer prescriptions for hypnotic drugs, and 6.5 fewer prescriptions for other drugs than fluoxetine patients. This shows that the total economic impact of initial antidepressant selection is broader than the acquisition costs of antidepressants.

Epidemiology and relative toxicity of antidepressant drugs in overdose

Antidepressant drugs are currently the mainstay of treatment for all but the mildest forms of depression. Their effectiveness in the management of depressive illness is undisputed and their effectiveness in preventing suicide, while not proven, may be assumed. Nevertheless, of all the drugs that are taken in lethal overdose, prescribed antidepressants are among the most common. Epidemiological studies from several countries have provided evidence of marked differences in overdose toxicity between drug classes and, in some cases, between individual drugs within a class, with some of the older tricyclic antidepressants (TCAs) being the most toxic. Over 80% of all deaths arising from overdose of antidepressant medication in the UK between 1987 and 1992 were caused by 2 drugs: amitriptyline and dothiepin. Taken alone, this figure conveys little information about the toxicity of either drug. However, when considered within an epidemiological context, the evidence suggests that both drugs are highly toxic in overdose, a conclusion that is supported by animal studies of the toxicity of TCAs and by clinical evidence of overdose toxicity. This paper reviews the epidemiological evidence concerning the acute toxicity of antidepressant drugs and considers the interplay of factors that contribute to the toxicity which occurs when they are taken in acute overdose. The inherent toxicity of the drug appears to be the crucial factor and, although less well researched, prescribing practices and perception of toxicity are probable contributory factors.

The treatment of depression: prescribing patterns of antidepressants in primary care in the UK

BACKGROUND

Consensus has been achieved about how depression should be treated in primary care, and guidelines have been issued by the Royal Colleges of General Practitioners and Psychiatrists, and by the British Association for Psychopharmacology. One of the principal recommendations is to prescribe antidepressant medicine at effective doses. This study was established to investigate how current prescribing practices in primary care compared with these guidelines.

METHOD

Information on prescribing of antidepressant medicines was obtained using three independent data sources: Prescribing Analysis and Cost (PACT) data; medical notes; and a large, computerised patient record database.

RESULTS

Data were obtained on populations in excess of 1.5 million people, and over 80,000 prescriptions were reviewed. All three data sources showed very similar patterns of prescribing, in particular that as many as 88% of prescriptions for older tricyclic antidepressants are prescribed by GPs at doses below those recommended by the consensus guidelines. Newer antidepressants-lofepramine and the SSRIs-are prescribed comparatively well.

CONCLUSIONS

Prescribing of antidepressants by GPs is not in line with the consensus recommendations on dosage. This may have major educational implications for GPs. A pragmatic approach to improve prescribing in the short term may be to advocate the use of lofepramine or the SSRIs as first line treatment for depression. This study validates the use of PACT data as a useful audit tool in this area of clinical practice.

The long-term management of depression

The long-term outlook for patients with unipolar depression is often poor. As few as one-fifth will remain well and a similar number will suffer chronic depression. It is now standard practice to extend acute treatment into a 4-6 month period of continuation therapy, and the value of prophylactic treatment over longer periods is becoming more widely recognised. Care must, however, be exercised in choosing suitable long-term treatment. Relatively little work on the prophylactic efficacy of the tricyclic antidepressants has been carried out, although imipramine has been shown to be effective. The selective serotonin re-uptake inhibitors (SSRIs) have been studied extensively and may be the most suitable long-term treatment for depression. Sertraline is effective in preventing both relapse and recurrence of depression and was the first agent specifically indicated for the long-term treatment of depression in the UK. In addition to clinical efficacy, many other factors favour SSRIs in the long-term management of depression. The tolerability of a drug is of major importance in long-term therapy since it affects compliance. Other important considerations include toxicity, safety in overdose, drug interaction potential, psychomotor effects and accident liability.

Treatment approaches to therapy-resistant depression

Resistance to antidepressant treatment is a controversial field and therapy resistance has received a wide range of definitions. The field has suffered from a lack of consensus on how to classify treatment resistance and from the related failure to standardise clinical criteria in trials of new therapeutic approaches. A significant proportion of tricyclic antidepressant (TCA)-resistant depression results from the failure to sustain an adequate course of therapy. This can be due to either inadequate prescribing or the poor tolerability of TCAs. The majority of cases of treatment resistance, however, involve antidepressant therapy at a dose and duration that would normally be expected to be effective. In these cases, therapy may fail for many reasons. Refractory depression may occur in patients with medical conditions such as subclinical hypothyroidism, stroke and closed head injuries. Patients with alcoholism may prove refractory to treatment, as may those receiving certain medications, notably calcium channel blockers. Certain subtypes of depression, such as rapid-cycling disorder and delusional depression, also appear to be more refractory to treatment. A variety of therapeutic approaches have been applied to treatment-resistant depression but, for most of these, placebo-controlled clinical trials with substantial numbers of patients have not been conducted. Selective serotonin re-uptake inhibitors (SSRIs) may have a role to play in TCA-resistant patients as a result of their superior tolerability; monoamine oxidase inhibitors (MAOIs) also have a significant therapeutic role. ECT has an important role to play in patients who failed to respond to successive drug therapies. Of the various add-on therapies, thyroid augmentation (triiodothyronine) of antidepressant treatment has shown promise, and definite benefits have been established for lithium augmentation. Evidence has emerged to show that lithium is not only effective as an adjunct to TCA therapy, but also to the better tolerated SSRIs. However, further trials will be necessary to determine the optimal dosage and treatment duration for lithium augmentation.