Der Nervenarzt

, 82:1425 | Cite as

Überlegungen zur Wirksamkeit von Psychopharmaka

Leitthema

Zusammenfassung

Aktuelle systematische Übersichtsarbeiten ergaben relativ kleine Wirksamkeitseffektstärken verschiedener Psychopharmaka im Vergleich zu Placebo. Diese Effektstärken scheinen zudem im Vergleich zu früheren Metaanalysen abgenommen zu haben. Im vorliegenden Artikel spekulieren die Autoren über mögliche Ursachen dieses Wirksamkeitsrückganges wie geringere methodische Ansprüche an ältere Studien, aber insbesondere auch methodische Probleme aktueller Studien wie z. B. chronische Patientenpopulationen, Ausschluss schwerkranker Patienten durch die Studienprotokolle, Sponsoring durch die pharmazeutische Industrie und sog. „professionelle Studienteilnehmer“.

Anhand einiger Beispiele aus der Allgemeinmedizin wird zudem verdeutlicht, dass die Effektstärken von Medikamenten anderer medizinischer Fachbereiche in aktuellen Metaanalysen oftmals auch überraschend gering sind. Psychopharmaka sind wirksam, sie müssen jedoch nach evidenzbasierten Kriterien und maßvoll eingesetzt werden.

Schlüsselwörter

Systematischer Review Psychiatrie Psychopharmakologie Metaanalyse Wirksamkeit 

Considerations about the efficacy of psychopharmacological drugs

Summary

Current systematic reviews yielded relatively small efficacy effect sizes of different psychopharmacological agents compared to placebo. It seems that these effect sizes have decreased compared to earlier meta-analyses. We speculate about factors explaining the decrease of effect size such as lower methodological requirements for earlier randomised controlled trials, but in particular enormous methodological problems of current trials such as chronic patient populations, exclusion of severely ill patients by the protocols, sponsoring by the pharmaceutical industry and so-called professional patients. A few examples from general medicine are used to illustrate that the effect sizes of other medications are often also surprisingly small. Psychotropic drugs are efficacious, but they need to be prudently applied according to evidence-based criteria.

Keywords

Systematic review Psychiatry Psychopharmacology Meta-analysis Efficacy 

Literatur

  1. 1.
    Baigent C, Blackwell L, Collins R et al (2009) Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 373:1849–1860PubMedCrossRefGoogle Scholar
  2. 2.
    Baigent C, Keech A, Kearney PM et al (2005) Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 366:1267–1278PubMedCrossRefGoogle Scholar
  3. 3.
    Barbui C, Furukawa TA, Cipriani A (2008) Effectiveness of paroxetine in the treatment of acute major depression in adults: a systematic re-examination of published and unpublished data from randomized trials. CMAJ 178:296–305PubMedGoogle Scholar
  4. 4.
    Barbui C, Guaiana G, Hotopf M (2004) Amitriptyline for inpatients and SSRIs for outpatients with depression? Systematic review and meta-regression analysis 127. Pharmacopsychiatry 37:93–97PubMedCrossRefGoogle Scholar
  5. 5.
    Bech P, Cialdella P, Haugh MC et al (2000) Meta-analysis of randomised controlled trials of fluoxetine vs placebo and tricyclic antidepressants in the short-term treatment of major depression. Br J Psychiatry 176:421–428PubMedCrossRefGoogle Scholar
  6. 6.
    Blood Pressure Lowering Treatment Trialists‘ Collaboration (2003) Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet 362:1527–1535CrossRefGoogle Scholar
  7. 7.
    Buscemi N, Vandermeer B, Friesen C et al (2007) The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med 22:1335–1350PubMedCrossRefGoogle Scholar
  8. 8.
    Cole JO (1964) Phenothiazine treatment in acute schizophrenia. Arch Gen Psychiatry 10:246–261Google Scholar
  9. 9.
    Davis JM, Schaffer CB, Killian GA et al (1980) Important issues in the drug treatment of schizophrenia. Schizophr Bull 6:70–87PubMedGoogle Scholar
  10. 10.
    Davis JM, Wang Z, Janicak PG (1993) A quantitative analysis of clinical drug trials for the treatment of affective disorders. Psychopharmacol Bull 29:175–181PubMedGoogle Scholar
  11. 11.
    Fournier JC, DeRubeis RJ, Hollon SD et al (2010) Antidepressant drug effects and depression severity. A patient-level meta-analysis. JAMA 303:47–53PubMedCrossRefGoogle Scholar
  12. 12.
    Geddes JR, Carney SM, Davies C et al (2003) Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 361:653–661PubMedCrossRefGoogle Scholar
  13. 13.
    Hansen R, Gaynes B, Thieda P et al (2008) Meta-analysis of major depressive disorder relapse and recurrence with second-generation antidepressants. Psychiatr Serv 59:1121–1130PubMedCrossRefGoogle Scholar
  14. 14.
    Holbrook AM, Crowther R, Lotter A et al (2000) Meta-analysis of benzodiazepine use in the treatment of insomnia. CMAJ 162:225–233PubMedGoogle Scholar
  15. 15.
    Janicak PG, Davis JM, Preskorn SH, Ayd FJ (1993) Principles and practice of psychopharmacology. Williams and Wilkins, BaltimoreGoogle Scholar
  16. 16.
    Kirsch I, Deacon BJ, Huedo-Medina TB et al (2008) Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 5:e45PubMedCrossRefGoogle Scholar
  17. 17.
    Komossa K, Depping AM, Heres S et al (2009) Maintenance treatment with antipsychotic drugs for schizophrenia (protocol). Cochrane Database Syst Rev (4). Art. No.: CD008016. DOI 10.1002/14651858.CD008016Google Scholar
  18. 18.
    Law M, Morris JK, Jordan R, Wald N (2005) Headaches and the treatment of blood pressure: results from a meta-analysis of 94 randomized placebo-controlled trials with 24,000 participants. Circulation 112:2301–2306PubMedCrossRefGoogle Scholar
  19. 19.
    Lee VC, Rhew DC, Dylan M et al (2004) Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction. Ann Intern Med 141:693–704PubMedGoogle Scholar
  20. 20.
    Leucht S, Hierl S, Dold M et al (2011) Putting the efficacy of psychiatric and general medicine medication in perspective: a review of meta-analyses. Br J Psychiatry (in pess)Google Scholar
  21. 21.
    Leucht S, Kane JM, Kissling W et al (2005) What does the PANSS mean? Schizophr Res 79:231–238PubMedCrossRefGoogle Scholar
  22. 22.
    Leucht S, Kissling W, Davis JM (2009) Second-generation antipsychotic drugs for schizophrenia: can we resolve the conflict? Psychol Med 39:1591–1602PubMedCrossRefGoogle Scholar
  23. 23.
    Lieberman JA, Stroup TS, McEvoy JP et al (2005) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 353:1209–1223PubMedCrossRefGoogle Scholar
  24. 24.
    Linde K, Rossnagel K (2004) Propranolol for migraine prophylaxis. Cochrane Database Syst Rev:CD003225Google Scholar
  25. 25.
    Lopez AD, Mathers CD, Ezzati M et al (2006) Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 367:1747–1757PubMedCrossRefGoogle Scholar
  26. 26.
    McCrory DC, Gray RN (2003) Oral sumatriptan for acute migraine. Cochrane Database Syst Rev:CD002915Google Scholar
  27. 27.
    Moncrieff J (1995) Lithium revisited. A re-examination of the placebo-controlled trials of lithium prophylaxis in manic-depressive disorder. Br J Psychiatry 167:569–573PubMedCrossRefGoogle Scholar
  28. 28.
    Nelson HS, Weiss ST, Bleecker ER et al (2006) The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest 129:15–26PubMedCrossRefGoogle Scholar
  29. 29.
    Patel A, MacMahon S, Chalmers J et al (2008) Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 358:2560–2572PubMedCrossRefGoogle Scholar
  30. 30.
    Rice GP, Incorvaia B, Munari L et al (2001) Interferon in relapsing-remitting multiple sclerosis. Cochrane Database Syst Rev:CD002002Google Scholar
  31. 31.
    Sinyor M, Schaffer A, Levitt A (2010) The sequenced treatment alternatives to relieve depression (STAR*D) trial: a review. Can J Psychiatry 55:126–135PubMedGoogle Scholar
  32. 32.
    Soomro GM, Altman D, Rajagopal S, Oakley-Browne M (2008) Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database Syst Rev:CD001765Google Scholar
  33. 33.
    Storosum JG, Elferink AJ, van Zwieten BJ et al (2001) Short-term efficacy of tricyclic antidepressants revisited: a meta-analytic study. Eur Neuropsychopharmacol 11:173–180PubMedCrossRefGoogle Scholar
  34. 34.
    Medical Research Council (1948) Streptomycin in tuberculosis trials committee: streptomycin treatment of pulmonary tuberculosis. Br Med J 2:769–782CrossRefGoogle Scholar
  35. 35.
    Action to Control Cardiovascular Risk in Diabetes Study Group (2008) Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 358:2545–2559CrossRefGoogle Scholar
  36. 36.
    Clomipramine Collaborative Study Group (1991) Clomipramine in the treatment of patients with obsessive-compulsive disorder. Arch Gen Psychiatry 48:730–738Google Scholar
  37. 37.
    Turner EH, Matthews AM, Linardatos E et al (2008) Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 358:252–260PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Klinik und Poliklinik für Psychiatrie und PsychotherapieTechnische Universität MünchenMünchenDeutschland
  2. 2.Psychiatric InstituteUniversity of Chicago at IllinoisChicagoUSA

Personalised recommendations