How Should Primary Care Doctors Select Which Antidepressants to Administer?
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Clinicians can choose among various second-generation antidepressants for treating depressive disorders, such as major depressive disorder, subsyndromal depression, or dysthymia. Systematic reviews indicate that available drugs differ in frequency of administration, costs, and the risks of some adverse events but have similar efficacy for treating major depressive disorder. Furthermore, evidence does not support the choice of one antidepressant over another based on accompanying symptoms, such anxiety, insomnia, or pain. Available studies provide little guidance for clinicians about the benefits of second-generation antidepressants for treating dysthymia and subsyndromal depression. Evidence is also unclear about the comparative risks of serious adverse events, such as suicidality, seizures, fractures, increased bleeding, or serotonin syndrome. This article summarizes the best available evidence regarding comparative benefits and harms of second-generation antidepressants for treating depressive disorders.
KeywordsMajor depressive disorder Dysthymia Subsyndromal depression Second-generation antidepressants Treating depressive disorders Primary care
Dr. Gartlehner has received research support from Agency for Healthcare Research and Quality (AHRQ).
Dr. Thaler has received research support from AHRQ.
Mr. Hill has received research support from AHRQ and Foundation for the National Institutes of Health (FNIH).
Dr. Hansen has received research support from AHRQ and FNIH, and has served as a consultant for Novartis and Takeda.
Recently published papers of particular interest have been highlighted as: • Of importance •• Of outstanding importance
- 1.American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision. Washington, DC. 2000.Google Scholar
- 7.Berkrot B. US prescription drug sales hit $300 bln in 2009, e. Gary Hill, Editor 2010, Reuters.Google Scholar
- 9.Geddes JR, Freemantle N, Mason J et al. Selective serotonin reuptake inhibitors (SSRIs) versus other antidepressants for depression. The Cochrane Library (Cochrane Review), 2006(1).Google Scholar
- 11.Cipriani A, Furukawa TA, Geddes JR et al. Does randomized evidence support sertraline as first-line antidepressant for adults with acute major depression? A systematic review and meta-analysis, in J Clin Psychiatry 2008; 1732–42.Google Scholar
- 12.Omori IM, Watanabe N, Nakagawa A et al. Efficacy, tolerability and side-effect profile of fluvoxamine for major depression: Meta-analysis. Journal of Psychopharmacology 2009; 539–550.Google Scholar
- 13.Watanabe N, Omori IM, Nakagawa A et al. Mirtazapine versus other antidepressants in the acute-phase treatment of adults with major depression: Systematic review and meta-analysis, in Journal of Clinical Psychiatry 2008; 1404–1415.Google Scholar
- 16.Eckert L, Falissard B. Using meta-regression in performing indirect-comparisons: comparing escitalopram with venlafaxine XR. Curr Med Res Opin 2006;2313–21.Google Scholar
- 17.Eckert L and Lançon C. Duloxetine compared with fluoxetine and venlafaxine: Use of meta-regression analysis for indirect comparisons. BMC Psychiatry 2006.Google Scholar
- 18.•• Gartlehner G, Hansen RA, Morgan LC, et al. Comparative Benefits and Harms of Second-Generation Antidepressants for Treating Major Depressive Disorder: An Updated Meta-analysis. Ann Intern Med. 2011;155(11):772–85. This is the most recent and most comprehensive assessment of the comparative efficacy and safety of second-generation antidepressants for the treatment of depressive disorders..PubMedGoogle Scholar
- 19.Cipriani A, Furukawa TA, Salanti G et al. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet 2009;746–58.Google Scholar
- 25.Gartlehner G, Hansen RA, Morgan LC, et al. Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression: An Update of the 2007 Comparative Effectiveness Review. AHRQ. 2011;46:171.Google Scholar
- 38.Ventura D, Armstrong EP, Skrepnek GH, Haim Erder M. Escitalopram versus sertraline in the treatment of major depressive disorder: a randomized clinical trial. Curr Med Res Opin 2007; 245–50.Google Scholar
- 39.Clayton AH, Croft HA, Horrigan JP et al. Bupropion extended release compared with escitalopram: effects on sexual functioning and antidepressant efficacy in 2 randomized, double-blind, placebo-controlled studies. J Clin Psychiatry 2006;736–46.Google Scholar
- 40.Kennedy SH, Fulton KA, Bagby RM et al. Sexual function during bupropion or paroxetine treatment of major depressive disorder. Can J Psychiatry 2006;234–42.Google Scholar
- 45.Eli Lilly aC. Cymbalta - "Depression Hurts" campaign. 2011 26th January 2012]; Available from: http://www.youtube.com/watch?v–7d6Ra0n2pUA&feature=related
- 56.Perahia DG, Wang F, Mallinckrodt CH et al. Duloxetine in the treatment of major depressive disorder: a placebo- and paroxetine-controlled trial. Eur Psychiatry 2006; 367–78.Google Scholar
- 57.Eli Lilly aC. Duloxetine Versus Placebo and Paroxetine in the Acute Treatment of Major Depression, Study Group A. Clinical Study Summary: Study F1J-MC-HMAT. At: http://www.clinicalstudyresults.org/documents/company-study_170_0.pdf (Accessed 08/24/2006). 2004.
- 58.Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry, 2000; 157(4 Suppl):1–45.Google Scholar
- 59.Hansen R, Gaynes B, Thieda P et al. Meta-analysis of major depressive disorder relapse and recurrence with second-generation antidepressants. Psychiatr Serv 2008;1121–30.Google Scholar
- 60.Bauer M, Tharmanathan P, Volz HP et al. The effect of venlafaxine compared with other antidepressants and placebo in the treatment of major depression: a meta-analysis. Eur Arch Psychiatry Clin Neurosci 2009;172–85.Google Scholar
- 61.Soares CN, Thase ME, Clayton A et al. Desvenlafaxine and escitalopram for the treatment of postmenopausal women with major depressive disorder. Menopause 2010;700–11.Google Scholar
- 62.Baldwin DS, Cooper JA, Huusom AK, Hindmarch I. A double-blind, randomized, parallel-group, flexible-dose study to evaluate the tolerability, efficacy and effects of treatment discontinuation with escitalopram and paroxetine in patients with major depressive disorder. Int Clin Psychopharmacol 2006;159–69.Google Scholar
- 64.Keller MB, Trivedi MH, Thase ME et al. The Prevention of Recurrent Episodes of Depression with Venlafaxine for Two Years (PREVENT) Study: Outcomes from the 2-year and combined maintenance phases. J Clin Psychiatry 2007; 1246–56.Google Scholar
- 68.Rush AJ, Trivedi MH, Wisniewski SR et al. Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. Am J Psychiatry 2006;1905–17.Google Scholar
- 69.Trivedi MH, Fava M, Wisniewski SR. et al. Medication augmentation after the failure of SSRIs for depression. N Engl J Med 2006;1243–52.Google Scholar
- 71.Fang Y, Yuan C, Xu Y et al. Comparisons of the efficacy and tolerability of extended-release venlafaxine, mirtazapine, and paroxetine in treatment-resistant depression: a double-blind, randomized pilot study in a Chinese population. J Clin Psychopharmacol 2010;357–64.Google Scholar
- 74.Corya SA, Williamson D, Sanger TM et al. A randomized, double-blind comparison of olanzapine/fluoxetine combination, olanzapine, fluoxetine, and venlafaxine in treatment-resistant depression. Depress Anxiety 2006;364–72.Google Scholar
- 79.Blier P, Gobbi G, Turcotte JE et al. Mirtazapine and paroxetine in major depression: a comparison of monotherapy versus their combination from treatment initiation. Eur Neuropsychopharmacol 2009;457–65.Google Scholar
- 96.Rahme E, Dasgupta K, Turecki G et al. Risks of suicide and poisoning among elderly patients prescribed selective serotonin reuptake inhibitors: a retrospective cohort study. J Clin Psychiatry 2008;349–57.Google Scholar
- 98.• Barbui C, Esposito E, Cipriani A. Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. CMAJ. 2009;180(3):291–7. Suicidal attempts or suicides are rare but severe adverse effects of second-generation antidepressants. Randomized controlled trials are usually too small to assess the excess risk of suicidality. This study provides a meta-analyses of large observational studies..PubMedCrossRefGoogle Scholar