Antidepressants versus placebo for generalised anxiety disorder (GAD)

BACKGROUND

Generalised anxiety disorder (GAD) is a mental health condition characterised by excessive anxiety and worry about everyday events. GAD is a common disorder and generally affects women twice as often as men. Treatments include various psychological and pharmacological therapies. Among the pharmacological therapies, antidepressants, in particular, selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs), are commonly used for the treatment of GAD and many studies have shown their benefit over placebo. Only one systematic review and meta-analysis comparing all antidepressants to placebo has been done in the past. Since then, new data on existing antidepressants have emerged and new antidepressants have been introduced. An updated and more comprehensive review is needed to provide a stronger understanding of the efficacy, acceptability, tolerability, and impact on the quality of life of the various types of antidepressants compared to placebo.

OBJECTIVES

To assess the effects of antidepressants in GAD in adults, specifically: to determine the efficacy of antidepressants in alleviating symptoms of GAD compared to placebo and to review the acceptability of antidepressants in GAD in terms of adverse effects, including the general prevalence of adverse effects compared to placebo.

SEARCH METHODS

We searched the Cochrane Common Mental Health Disorders (CCMD) register, CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers in October 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCT) or cluster-RCTs that randomly assigned participants to receive either an antidepressant or placebo for the treatment of GAD. There were no restrictions on dose, frequency, intensity, or duration of treatment. The studies included adults of either sex with a primary diagnosis of GAD and without any serious medical comorbidities. Psychiatric comorbidities were allowed as long as GAD was the primary diagnosis. We excluded studies investigating psychotherapies and those that included participants who had regular use of benzodiazepines. There were no restrictions on setting, country, or language.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked eligibility and extracted data following standard Cochrane methodological procedures. We assessed risk of bias using the Cochrane RoB 1 tool. A third review author resolved disagreements between the two primary review authors. We extracted study characteristics, participant characteristics, intervention details, settings, and outcome measures regarding efficacy, acceptability, tolerability, and quality of life. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 37 unique RCTs with 12,226 participants in the review. The studies included adults with moderate-severe GAD and without any serious medical comorbidities. Few studies included participants with secondary psychiatric comorbidities. The double-blind treatment duration ranged from four weeks to 28 weeks. Antidepressants have a benefit over placebo on rate of treatment response measured as a reduction of at least 50% on the Hamilton Anxiety Rating Scale (HAM-A) (risk ratio (RR) 1.41, 95% confidence interval (CI) 1.29 to 1.55; 20 studies, 7267 participants; high-certainty evidence). The magnitude of effect corresponds to a number needed to treat for an additional beneficial outcome (NNTB) of 7 (95% CI 5 to 9). Antidepressants have no difference in acceptability compared to placebo, measured as the number of participants who dropped out during the trial as a proportion of the total number of randomised participants (RR 1.03, 95% CI 0.93 to 1.14; 33 studies, 11,294 participants; high-certainty evidence). Fewer participants dropped out due to a lack of efficacy in the antidepressant group compared to the placebo group (RR 0.41, 95% CI 0.33 to 0.50; 29 studies, 11,007 participants; high-certainty evidence) with an NNTB of 27 (95% CI 24 to 32), and more participants dropped out due to adverse effects in the antidepressant group compared to placebo (RR 2.18, 95% CI 1.81 to 2.61; 32 studies, 11,793 participants; high-certainty evidence) with a number needed to treat for an additional harmful outcome (NNTH) of 17 (95% CI 13 to 112). We observed similar findings when classes of antidepressants were compared with placebo. The certainty of the evidence for the analyses comparing different classes of antidepressants to placebo was high.

AUTHORS' CONCLUSIONS

This review added to the growing literature on antidepressants in the treatment of GAD. We have high confidence that antidepressants are more effective than placebo at improving treatment response and that antidepressants have similar acceptability to placebo. Fewer participants dropped out due to a lack of efficacy in the antidepressant group compared to the placebo group and more participants dropped out due to adverse effects in the antidepressant group compared to placebo. We are highly confident in this evidence. This review identified some important gaps in the literature on antidepressants for GAD and can be used as a tool to guide future research. Future studies may be more transparent with their methodology and outcome reporting. Future reviews may also include people with comorbidities, and explore other sources of heterogeneity.

Preoperative duloxetine on postoperative pain after laparoscopic gynecological surgeries: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy and safety of preoperative duloxetine on postoperative pain management after gynecologic laparoscopic surgeries.

METHODS

A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus from inception to September 2021. We selected randomized clinical trials (RCTs) that compared preoperative duloxetine (intervention group) versus placebo (control group) among women undergoing gynecologic laparoscopic surgeries. Our primary outcomes were pain scores evaluated by the Visual Analog Scale (VAS) at 2, 6, 12, and 24 h postoperatively. Our secondary outcomes were the time required for the first analgesic request in minutes, postoperative analgesic consumption in milligrams, length of hospital stay in days, and side effects.

RESULTS

Four RCTs with a total number of 244 patients were included in our systematic review and meta-analysis. We found duloxetine was linked to a significant reduction in VAS pain scores at different time intervals. The first analgesic request was significantly earlier in the placebo group than in the duloxetine group (p = 0.03). In addition, duloxetine significantly reduced the postoperative analgesic consumption compared to placebo (MD= -41.97, 95% CI [-53.23, -30.72], p<0.001). However, both groups did not differ in the length of hospital stay and side effects.

CONCLUSIONS

Duloxetine administration prior to gynecological laparoscopic surgeries is safe and effective in improving postoperative pain and analgesia.

WITHDRAWN: Preoperative duloxetine to prevent postoperative shoulder pain after gynecologic laparoscopy: a randomized controlled trial

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Whole-brain activation signatures of weight-lowering drugs

OBJECTIVE

The development of effective anti-obesity therapeutics relies heavily on the ability to target specific brain homeostatic and hedonic mechanisms controlling body weight. To obtain further insight into neurocircuits recruited by anti-obesity drug treatment, the present study aimed to determine whole-brain activation signatures of six different weight-lowering drug classes.

METHODS

Chow-fed C57BL/6J mice (n = 8 per group) received acute treatment with lorcaserin (7 mg/kg; i.p.), rimonabant (10 mg/kg; i.p.), bromocriptine (10 mg/kg; i.p.), sibutramine (10 mg/kg; p.o.), semaglutide (0.04 mg/kg; s.c.) or setmelanotide (4 mg/kg; s.c.). Brains were sampled two hours post-dosing and whole-brain neuronal activation patterns were analysed at single-cell resolution using c-Fos immunohistochemistry and automated quantitative three-dimensional (3D) imaging.

RESULTS

The whole-brain analysis comprised 308 atlas-defined mouse brain areas. To enable fast and efficient data mining, a web-based 3D imaging data viewer was developed. All weight-lowering drugs demonstrated brain-wide responses with notable similarities in c-Fos expression signatures. Overlapping c-Fos responses were detected in discrete homeostatic and non-homeostatic feeding centres located in the dorsal vagal complex and hypothalamus with concurrent activation of several limbic structures as well as the dopaminergic system.

CONCLUSIONS

Whole-brain c-Fos expression signatures of various weight-lowering drug classes point to a discrete set of brain regions and neurocircuits which could represent key neuroanatomical targets for future anti-obesity therapeutics.

Duloxetine in treating generalized anxiety disorder in adults: A meta-analysis of published randomized, double-blind, placebo-controlled trials

INTRODUCTION

We carried out a meta-analysis of published randomized, double-blind, placebo-controlled trails to assess the efficacy and tolerability of duloxetine in treating generalized anxiety disorder (GAD).

METHODS

A literature search was conducted using PubMed, ISI Web of Science, Medline, Cochrane Central Register of Controlled Trials databases until October 2014. The search terms used were "anxiety or anxious or generalized anxiety disorder" and "duloxetine or Cymbalta." Meta-analysis was conducted using Revman 5.1. A fixed-effects model was carried out on the response rates, remission rates, and symptom improvement. Risk ratio (RR) and mean difference (MD) were calculated. The overall effect size was calculated with 95% confidence intervals (CIs).

RESULTS

Seven studies (n = 2,674) were found eligible for inclusion in analysis. Six studies provided data on response, which showed a significant difference between duloxetine and placebo (n = 1,975, RR = 1.48, 95% CI, 1.34-1.63). Remission rates revealed significant superiority of duloxetine (n = 2,399, RR = 1.60, 95% CI, 1.43-1.80). Change from baseline scores on Hamilton Rating Scale for Anxiety showed a reduction in anxiety symptoms to be significantly efficient for duloxetine (n = 1,135, MD = 3.34, 95% CI, 2.37-4.32). Duloxetine increased statistically Sheehan Disability Scale total score (n = 1,652, MD = 2.84, 95% CI, 2.08-3.60). The discontinuation of the duloxetine was not significantly different from that of the placebo.

CONCLUSION

Duloxetine is moderately effective in treating GAD with improvement in overall function and well tolerability.

Treatment of major depressive disorders with generic duloxetine and paroxetine: a multi-centered, double-blind, double-dummy, randomized controlled clinical trial

Background

This study is a pre-registration trial of generic duloxetine that was approved by the China Food and Drug Administration (approval number: 2006L01603).

Aims

Compare the treatment efficacy and safety of generic duloxetine to that of paroxetine in patients with major depressive disorders (MDD).

Methods

This was a double-dummy, double-blind, multicenter, positive drug (paroxetine), parallel randomized controlled clinical trial. The 299 patients with MDD recruited for the study were randomly assigned to use duloxetine (n=149; 40–60 mg/d) or paroxetine (n=150; 20 mg/d) for 8 weeks. The Hamilton Depression rating scale (HAMD-17) was administered at baseline and 1, 2, 4, 6, and 8 weeks after starting treatment. Remission was defined as a HAMD-17 score below 8 at the end of the trial, and treatment effectiveness was defined as a decrease in baseline HAMD-17 score of at least 50% by the end of the trial. Safety was assessed based on the reported prevalence and severity of side effects and changes in laboratory and electrocardiographic findings. Three patients in the duloxetine group dropped out before starting medication, so results were analyzed using a modified intention-to-treat (ITT) method with 146 in the experimental group and 150 in the control group.

Results

Both groups experienced 29 dropouts during the 8-week trial. HAMD-17 scores decreased significantly from baseline throughout the trial in both groups. Based on the ITT analysis, at the end of the trial there was no significant difference between the duloxetine group and the paroxetine group in effectiveness (67.1% v. 71.3%, X²=0.62 p=0.433), remission rate (41.1% v. 51.3%, X²=3.12, p=0.077), or in the incidence of side effects (56.8% v. 54.7%, X²=0.14, p=0.705).

Conclusions

Generic duloxetine is as effective and safe as paroxetine in the acute treatment of patients with MDD who seek care at psychiatric outpatient departments in China.

A randomized, placebo-controlled study of duloxetine for the treatment of children and adolescents with generalized anxiety disorder

OBJECTIVE

To evaluate the efficacy, safety, and tolerability of the selective serotonin norepinephrine inhibitor duloxetine in children and adolescents with generalized anxiety disorder (GAD).

METHOD

Youth aged 7 through 17 years with a primary diagnosis of GAD were treated with flexibly dosed duloxetine (30-120 mg daily, n = 135) or placebo (n = 137) for 10 weeks, followed by open-label duloxetine (30-120mg daily) for 18 weeks. Efficacy measures included the Pediatric Anxiety Rating Scale (PARS), Clinical Global Impression-Severity (CGI-Severity) scale, and Children's Global Assessment Scale (CGAS). Safety measures included the Columbia-Suicide Severity Rating Scale (C-SSRS) as well as vital signs and electrocardiographic and laboratory monitoring.

RESULTS

On the primary efficacy measure (PARS severity for GAD), mean improvement from baseline to 10 weeks was statistically significantly greater for duloxetine (-9.7) compared with placebo (-7.1, p ≤ .001, Cohen's d: 0.5). Symptomatic response (50% improvement on the PARS severity for GAD), remission (PARS severity for GAD ≤8), and functional remission (CGAS >70) rates for the duloxetine group (59%, 50%, 37%, respectively) were statistically significantly greater than for the placebo group (42%, 34%, 24%, respectively, p ≤ .05) during acute treatment. Changes in systolic and diastolic blood pressure and discontinuation because of adverse events did not statistically differ between the duloxetine and placebo groups, although gastrointestinal-related adverse events, oropharyngeal pain, dizziness, cough, and palpitations were reported with a statistically significantly greater incidence for the duloxetine group compared with the placebo group. Mean changes in pulse and weight for the duloxetine group (+6.5 beats/min, -0.1 kg, respectively) were statistically different from the placebo group (+2.0 beats/min, +1.1 kg, respectively, p ≤ .01).

CONCLUSION

In this study, duloxetine was superior to placebo on the primary efficacy analysis of mean change from baseline to week 10 on the PARS severity for GAD score, and safety results were consistent with the known safety profile of duloxetine in pediatric and adult patients. Clinical trial registration information-A Study in Pediatric Participants With Generalized Anxiety Disorder; http://clinicaltrials.gov; NCT01226511.

Duloxetine in affective disorders: a naturalistic study on psychiatric and medical comorbidity, use in association and tolerability across different age groups

Objective:

Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor (SNRI), is currently approved in many countries for the treatment of Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD). The present naturalistic study was aimed to investigate tolerability of Duloxetine in a sample of patients with affective disorders and psychiatric/medical comorbidity, comparing tolerability in monotherapy versus polytherapy and across different age groups.

Methods:

The sample included 165 patients, affected by anxiety and/or mood disorders with or without comorbidity, who had been taken Duloxetine for at least 1 month. Sample variables were collected through a retrospective chart review.

Results:

Most common primary diagnoses were MDD (49.1 %), Bipolar Disorder (BD) (15.7 %) and GAD (5.5%). The 40 % of the sample had psychiatric comorbidity: in particular, anxiety disorders (15.8 %) (GAD 7.9%, Panic Disorder –PD- 7.3%) and personality disorders (9.1%) as the most frequent ones. With respect to medical comorbidities (68% of the sample), hypertension (12.1%) and diabetes (7.3%) were the most common ones. Mean duration of treatment and dosage of Duloxetine were, respectively, 11 months (± 9.1) and 70 mg/day (± 28.6). The 68 % of the sample received Duloxetine in association with other drugs. Minor side-effects, in particular drowsiness and gastrointestinal problems, were reported by 15 % of the sample. No difference in terms of tolerability across distinct groups, divided on the basis of mono- vs polytherapy as well as of different age, was found.

Conclusion:

Duloxetine, mostly administered in patients with affective disorders with psychiatric/ medical comorbidity and in association with other drugs, appeared to be well tolerated, showing limited rates of side effects of mild intensity. Further naturalistic studies are warranted to confirm present results.

Long-term safety of duloxetine during open-label compassionate use treatment of patients who completed previous duloxetine clinical trials

PURPOSE

To provide duloxetine for the treatment of major depressive disorder (MDD), generalized anxiety disorder (GAD), fibromyalgia (FM) and diabetic peripheral neuropathic pain (DPNP) to patients who had previously completed a duloxetine clinical study and for whom, in the opinion of the investigator, no effective alternative therapy was available.

METHODS

Adult outpatients who had previously completed a duloxetine study for the treatment of MDD, GAD, DPNP, or FM received duloxetine 30 mg to 120 mg daily up until its local commercial availability. Safety analyses included treatment-emergent adverse events (TEAEs), serious adverse events (SAEs), AEs reported as reason for discontinuation, and vital signs. No efficacy measures were collected.

RESULTS

Of 667 patients enrolled, 282 (42.3%) were still participating at the time the drug was made commercially available in their countries. Most patients had previously participated in a duloxetine MDD study (76.2%); were female (68.1%) and Caucasian (94.9%). The median duration of exposure was 328 days (range 3-1718 days). The most common reasons for discontinuation were patient decision (25.3%), adverse event (8.4%), and lack of efficacy (8.4%). Of the 86 SAEs experienced by 46 patients, most (including one death) were judged by the investigator to be unrelated to duloxetine treatment. The most common TEAEs were in the System Organ Class of gastrointestinal (28.3%), nervous system (28.0%), and psychiatric (25.8%) and were predominantly mild to moderate in severity. Increases of systolic blood pressure (1.9 mm Hg) and pulse rate (2.2 bpm) at endpoint were reported.

CONCLUSION

The safety data from this long-term compassionate use study of duloxetine were consistent with previous experience and revealed no new safety signals.

LIMITATIONS

The limitations include: lack of a control arm, no efficacy data were collected to assess the long-term efficacy, the results may not necessarily generalize to other ethnic groups as most patients were Caucasians, and lack of consistency in regard to duration of exposure at study entry as patients came from different trials with different study designs. CLINICAL TRIAL REGISTRY ID: www.clinicaltrials.gov--NCT00071708.

Use of duloxetine in patients with an anxiety disorder, or with comorbid anxiety and major depressive disorder: a review of the literature

IMPORTANCE OF THE FIELD

Except for generalized anxiety disorder, few reports have been published on the efficacy, safety and tolerability of duloxetine in patients with anxiety disorders individually or in comorbidity with major depressive disorder (MDD).

AREAS COVERED IN THIS REVIEW

The literature search in Medline (dating back to 1966) and Embase (dating back to 1988) databases was conducted using the OVID interface on 9 April 2009, restricted to any article or abstract in English, per title, reporting any information on the use of duloxetine in patients with any anxiety disorder with or without concomitant MDD. A systematic review approach was taken.

WHAT THE READER WILL GAIN

The reader will gain knowledge of the current data available on the use of duloxetine to treat patients with anxiety disorders individually or in comorbidity with MDD.

TAKE HOME MESSAGE

Duloxetine could be considered an effective treatment option in the treatment of anxiety disorders individually or in comorbidity with each other, or with MDD; however, apart from the well-demonstrated efficacy, tolerability and safety of duloxetine in the treatment of MDD with or without anxiety and GAD, data on this subject are preliminary and very limited, and more research is warranted.