Abstract
Antidepressants were first developed serendipitously 60 years ago and gave rise to the monoamine hypothesis of depression and antidepressant action which has persisted in various forms ever since. Although we have made huge strides in our understanding of the pharmacology of antidepressants, and in the neuroscience of depression, our current antidepressants have changed little since the original drugs. In this chapter I first review some controversies in the use of antidepressant drugs including whether they actually work, and then go on to describe the current state of our clinical use of antidepressants, looking both at the principles and practice of treatment and reviewing the evidence for efficacy, tolerability and safety in acute and sequenced treatments. I finally briefly consider future directions and the aspiration of developing more effective antidepressants.
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References
Adli M, Baethge C, Heinz A et al (2005) Is dose escalation of antidepressants a rational strategy after a medium-dose treatment has failed? A systematic review. Eur Arch Psychiatry Clin Neurosci 255:387–400
Anderson IM (2001) Meta-analytical studies on new antidepressants. Br Med Bull 57:161–178
Anderson IM (2003) Drug treatment of depression: reflections on the evidence. Adv Psychiatr Treat 9:11–20
Anderson I (2009) Commentary on STAR*D: a summary and UK perspective. J Psychopharmacol 23:613–614
Anderson IM, Haddad PM (2011) Prescribing antidepressants for depression: time to be dimensional and inclusive. Br J Gen Pract 61:50–52
Anderson IM, Ferrier IN, Baldwin RC et al (2008) Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines. J Psychopharmacol 22:343–396
Andrews PW, Kornstein SG, Halberstadt LJ et al (2011) Blue again: perturbational effects of antidepressants suggest monoaminergic homeostasis in major depression. Front Psychol 2:159 Epub 7 Jul 2011
Angst J, Stabl M (1992) Efficacy of moclobemide in different patient groups: a meta-analysis of studies. Psychopharmacology 106(Suppl):S109–S113
Baldwin DS, Stein DJ, Dolberg OT et al (2009) How long should a trial of escitalopram treatment be in patients with major depressive disorder, generalised anxiety disorder or social anxiety disorder? an exploration of the randomised controlled trial database. Hum Psychopharmacol 24:269–275
Ban TA (2001) Pharmacotherapy of mental illness—a historical analysis. Prog Neuropsychopharmacol Biol Psychiatry 25:709–727
Barr LC, Heninger GR, Goodman W et al (1997) Effects of fluoxetine administration on mood response to tryptophan depletion in healthy subjects. Biol Psychiatry 41:949–954
Bauer M, Adli M, Bschor T et al (2010) Lithium’s emerging role in the treatment of refractory major depressive episodes: augmentation of antidepressants. Neuropsychobiology 62:36–42
Blier P, Ward HE, Tremblay P et al (2010) Combination of antidepressant medications from treatment initiation for major depressive disorder: a double-blind randomized study. Am J Psychiatry 167:281–288
Bostwick JM, Pankratz VS (2000) Affective disorders and suicide risk: a reexamination. Am J Psychiatry 157:1925–1932
Brunoni AR, Tadini L, Fregni F (2010) Changes in clinical trials methodology over time: a systematic review of six decades of research in psychopharmacology. PLoS One 5:9479
Carrasco JL, Sandner C (2005) Clinical effects of pharmacological variations in selective serotonin reuptake inhibitors: an overview. Int J Clin Pract 59:1428–1434
Cipriani A, Furukawa TA, Salanti G et al (2009) Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet 373:746–758
Corya SA, Williamson D, Sanger TM et al (2006) A randomized, double-blind comparison of olanzapine/fluoxetine combination, olanzapine, fluoxetine, and venlafaxine in treatment-resistant depression. Depress Anxiety 23:364–372
Curry J, Silva S, Rohde P et al (2011) Recovery and recurrence following treatment for adolescent major depression. Arch Gen Psychiatry 68:263–269
Eyding D, Lelgemann M, Grouven U et al (2010) Reboxetine for acute treatment of major depression: systematic review and meta-analysis of published and unpublished placebo and selective serotonin reuptake inhibitor controlled trials. BMJ 341:c4737. doi:10.1136/bmj.c4737
Fava M, Rush AJ, Wisniewski SR et al (2006) A comparison of mirtazapine and nortriptyline following two consecutive failed medication treatments for depressed outpatients: a STAR*D report. Am J Psychiatry 163:1161–1172
Food and Drug Administration (2011) FDA Drug Safety Communication: abnormal heart rhythms associated with high doses of Celexa (citalopram hydrobromide). Safety Announcement [08-24-2011]. http://www.fda.gov/Drugs/DrugSafety/ucm269086.htm
Fountoulakis KN, Moller HJ (2011) Efficacy of antidepressants: a re-analysis and re-interpretation of the Kirsch data. Int J Neuropsychopharmacol 14:405–412
Fournier JC, DeRubeis RJ, Hollon SD et al (2010) Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 303:47–53
Friedman ES, Anderson IM (2010) Managing depression in clinical practice. Springer-Verlag, London
Gartlehner G, Hansen RA, Morgan LC et al (2011) Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder: an updated meta-analysis. Ann Intern Med 155:772–785
Geddes JR, Carney SM, Davies C et al (2003) Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 361:653–661
Gelenberg AJ, Thase ME, Meyer RE et al (2008) The history and current state of antidepressant clinical trial design: a call to action for proof-of-concept studies. J Clin Psychiatry 69:1513–1528
Guzzetta F, Tondo L, Centorrino F et al (2007) Lithium treatment reduces suicide risk in recurrent major depressive disorder. J Clin Psychiatry 68:380–383
Hammad TA, Laughren T, Racoosin J (2006) Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 63:332–339
Hawton K, Bergen H, Simkin S et al (2010) Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. Br J Psychiatry 196:354–358
Hickie IB, Rogers NL (2011) Novel melatonin-based therapies: potential advances in the treatment of major depression. Lancet 378:621–631
Holtzheimer PE, Mayberg HS (2011) Stuck in a rut: rethinking depression and its treatment. Trends Neurosci 34:1–9
Keers R, Uher R, Huezo-Diaz P et al (2011) Interaction between serotonin transporter gene variants and life events predicts response to antidepressants in the GENDEP project. Pharmacogenomics J 11:138–145
Keller MB (2003) Past, present, and future directions for defining optimal treatment outcome in depression: remission and beyond. JAMA 289:3152–3160
Kennedy SH, Andersen HF, Thase ME (2009) Escitalopram in the treatment of major depressive disorder: a meta-analysis. Curr Med Res Opin 25:161–175
King M, Nazareth I, Lampe F et al (2005) Impact of participant and physician intervention preferences on randomized trials: a systematic review. JAMA 293:1089–1099
Kirsch I, Moncrieff J (2007) Clinical trials and the response rate illusion. Contemp Clin Trials 28:348–351
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:e45
Kocsis JH, Leon AC, Markowitz JC et al (2009) Patient preference as a moderator of outcome for chronic forms of major depressive disorder treated with nefazodone, cognitive behavioral analysis system of psychotherapy, or their combination. J Clin Psychiatry 70:354–361
Lin P, Campbell DG, Chaney EF et al (2005) The influence of patient preference on depression treatment in primary care. Ann Behav Med 30:164–173
McCabe C, Mishor Z, Cowen PJ et al (2010) Diminished neural processing of aversive and rewarding stimuli during selective serotonin reuptake inhibitor treatment. Biol Psychiatry 67:439–445
McGrath PJ, Stewart JW, Fava M et al (2006) Tranylcypromine versus venlafaxine plus mirtazapine following three failed antidepressant medication trials for depression: a STAR*D report. Am J Psychiatry 163:1531–1541
McIntyre RS, Muzina DJ, Adams A et al (2009) Quetiapine XR efficacy and tolerability as monotherapy and as adjunctive treatment to conventional antidepressants in the acute and maintenance treatment of major depressive disorder: a review of registration trials. Expert Opin Pharmacother 10:3061–3075
Melander H, Salmonson T, Abadie E et al (2008) A regulatory Apologia—a review of placebo-controlled studies in regulatory submissions of new-generation antidepressants. Eur Neuropsychopharmacol 18:623–627
Mergl R, Henkel V, Allgaier AK et al (2011) Are treatment preferences relevant in response to serotonergic antidepressants and cognitive-behavioral therapy in depressed primary care patients? results from a randomized controlled trial including a patients’ choice arm. Psychother Psychosom 80:39–47
Middleton H, Moncrieff J (2011) ‘They won’t do any harm and might do some good’: time to think again on the use of antidepressants? Br J Gen Pract 61:47–49
Moller HJ, Bitter I, Bobes J et al (2012) Position statement of the European Psychiatric Association (EPA) on the value of antidepressants in the treatment of unipolar depression. Eur Psychiatry 27:114–128
Moncrieff J (2006) Why is it so difficult to stop psychiatric drug treatment? it may be nothing to do with the original problem. Med Hypotheses 67:517–523
Moncrieff J, Wessely S, Hardy R (2004) Active placebos versus antidepressants for depression. Cochrane Database Syst Rev CD003012
National Institute for Health and Clinical Excellence (2009a) Clinical guideline 90. Depression in adults (update): full guideline. http://guidance.nice.org.uk/CG90/Guidance
National Institute for Health and Clinical Excellence (2009b) Clinical guideline 91. Depression in adults with a chronic health problem: full guideline. http://guidance.nice.org.uk/CG91/Guidance
Newnham EA, Hooke GR, Page AC (2010) Progress monitoring and feedback in psychiatric care reduces depressive symptoms. J Affect Disord 127:139–146
Nierenberg AA, McLean NE, Alpert JE et al (1995) Early nonresponse to fluoxetine as a predictor of poor 8-week outcome. Am J Psychiatry 152:1500–1503
Nierenberg AA, Farabaugh AH, Alpert JE et al (2000) Timing of onset of antidepressant response with fluoxetine treatment. Am J Psychiatry 157:1423–1428
Nierenberg AA, Fava M, Trivedi MH et al (2006) A comparison of lithium and T(3) augmentation following two failed medication treatments for depression: a STAR*D report. Am J Psychiatry 163:1519–1530
Nutt DJ (2009) Beyond psychoanaleptics—can we improve antidepressant drug nomenclature? J Psychopharmacol 23:343–345
Opbroek A, Delgado PL, Laukes C et al (2002) Emotional blunting associated with SSRI-induced sexual dysfunction: do SSRIs inhibit emotional responses? Int J Neuropsychopharmacol 5:147–151
Papakostas GI, Shelton RC, Smith J et al (2007a) Augmentation of antidepressants with atypical antipsychotic medications for treatment-resistant major depressive disorder: a meta-analysis. J Clin Psychiatry 68:826–831
Papakostas GI, Thase ME, Fava M et al (2007b) Are antidepressant drugs that combine serotonergic and noradrenergic mechanisms of action more effective than the selective serotonin reuptake inhibitors in treating major depressive disorder? A meta-analysis of studies of newer agents. Biol Psychiatry 62:1217–1227
Papakostas GI, Fava M, Thase ME (2008a) Treatment of SSRI-resistant depression: a meta-analysis comparing within- versus across-class switches. Biol Psychiatry 63:699–704
Papakostas GI, Nelson JC, Kasper S et al (2008b) A meta-analysis of clinical trials comparing reboxetine, a norepinephrine reuptake inhibitor, with selective serotonin reuptake inhibitors for the treatment of major depressive disorder. Eur Neuropsychopharmacol 18:122–127
Papakostas GI, Charles D, Fava M (2010) Are typical starting doses of the selective serotonin reuptake inhibitors sub-optimal? A meta-analysis of randomized, double-blind, placebo-controlled, dose-finding studies in major depressive disorder. World J Biol Psychiatry 11:300–307
Portella MJ, de Diego-Adelino J, Ballesteros J et al (2011) Can we really accelerate and enhance the selective serotonin reuptake inhibitor antidepressant effect? a randomized clinical trial and a meta-analysis of pindolol in nonresistant depression. J Clin Psychiatry 72:962–969
Posternak MA, Zimmerman M (2005) Is there a delay in the antidepressant effect? a meta-analysis. J Clin Psychiatry 66:148–158
Posternak MA, Zimmerman M (2007) Therapeutic effect of follow-up assessments on antidepressant and placebo response rates in antidepressant efficacy trials: meta-analysis. Br J Psychiatry 190(287–92):287–292
Pratt L, Brody D, Gu Q (2011) Antidepressant use in persons aged 12 and over: United States, 2005–2008. NCHS data brief, no 76. National Center for Health Statistics, Hyattsville. http://www.cdc.gov/nchs/data/databriefs/db76.htm
Preskorn SH (2010) CNS drug development: part I: the early period of CNS drugs. J Psychiatr Pract 16:334–339
Preskorn SH (2011) CNS drug development: part III: future directions. J Psychiatr Pract 17:49–52
Price J, Cole V, Goodwin GM (2009) Emotional side-effects of selective serotonin reuptake inhibitors: qualitative study. Br J Psychiatry 195:211–217
Quitkin FM, Petkova E, McGrath PJ et al (2003) When should a trial of fluoxetine for major depression be declared failed? Am J Psychiatry 160:734–740
Rubino A, Roskell N, Tennis P et al (2007) Risk of suicide during treatment with venlafaxine, citalopram, fluoxetine, and dothiepin: retrospective cohort study. BMJ 334:242
Rudolph RL, Fabre LF, Feighner JP et al (1998) A randomized, placebo-controlled, dose-response trial of venlafaxine hydrochloride in the treatment of major depression. J Clin Psychiatry 59:116–122
Ruhe HG, Huyser J, Swinkels JA et al (2006) Switching antidepressants after a first selective serotonin reuptake inhibitor in major depressive disorder: a systematic review. J Clin Psychiatry 67:1836–1855
Ruhe HG, Mason NS, Schene AH (2007) Mood is indirectly related to serotonin, norepinephrine and dopamine levels in humans: a meta-analysis of monoamine depletion studies. Mol Psychiatry 12:331–359
Rush AJ (2007) STAR*D: what have we learned? Am J Psychiatry 164:201–204
Rush AJ, Trivedi MH, Wisniewski SR et al (2006a) Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 163:1905–1917
Rush AJ, Trivedi MH, Wisniewski SR et al (2006b) Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. N Engl J Med 354:1231–1242
Rush AJ, Trivedi MH, Stewart JW et al (2011) Combining medications to enhance depression outcomes (CO-MED): acute and long-term outcomes of a single-blind randomized study. Am J Psychiatry 168:689–701
Serretti A, Chiesa A (2009) Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol 29:259–266
Shelton RC, Williamson DJ, Corya SA et al (2005) Olanzapine/fluoxetine combination for treatment-resistant depression: a controlled study of SSRI and nortriptyline resistance. J Clin Psychiatry 66:1289–1297
Simon GE, Perlis RH (2010) Personalized medicine for depression: can we match patients with treatments? Am J Psychiatry 167:1445–1455
Simon GE, Savarino J (2007) Suicide attempts among patients starting depression treatment with medications or psychotherapy. Am J Psychiatry 164:1029–1034
Sinyor M, Levitt AJ, Cheung AH et al (2010) Does inclusion of a placebo arm influence response to active antidepressant treatment in randomized controlled trials? results from pooled and meta-analyses. J Clin Psychiatry 71:270–279
Smith D, Dempster C, Glanville J et al (2002) Efficacy and tolerability of venlafaxine compared with selective serotonin reuptake inhibitors and other antidepressants: a meta-analysis. Br J Psychiatry 180(396–404):396–404
Stone M, Laughren T, Jones ML et al (2009) Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US food and drug administration. BMJ 339:b2880. doi:10.1136/bmj.b2880
Szegedi A, Jansen WT, van Willigenburg AP et al. (2009) Early improvement in the first 2 weeks as a predictor of treatment outcome in patients with major depressive disorder: a meta-analysis including 6562 patients. J Clin Psychiatry 70:344–353
Tanti A, Belzung C (2010) Open questions in current models of antidepressant action. Br J Pharmacol 159:1187–1200
Thase ME, Shelton RC, Khan A (2006) Treatment with venlafaxine extended release after SSRI nonresponse or intolerance: a randomized comparison of standard- and higher-dosing strategies. J Clin Psychopharmacol 26:250–258
Thase ME, Friedman ES, Biggs MM et al (2007) Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D report. Am J Psychiatry 164:739–752
Thase ME, Larsen KG, Kennedy SH (2011) Assessing the ‘true’ effect of active antidepressant therapy v. placebo in major depressive disorder: use of a mixture model. Br J Psychiatry 199:501–507
Trivedi MH, Rush AJ, Crismon ML et al (2004) Clinical results for patients with major depressive disorder in the Texas Medication Algorithm Project. Arch Gen Psychiatry 61:669–680
Trivedi MH, Fava M, Wisniewski SR et al (2006) Medication augmentation after the failure of SSRIs for depression. N Engl J Med 354:1243–1252
Turner EH, Matthews AM, Linardatos E et al (2008) Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 358:252–260
Uher R, Maier W, Hauser J et al (2009) Differential efficacy of escitalopram and nortriptyline on dimensional measures of depression. Br J Psychiatry 194:252–259
Zarate CA Jr, Singh JB, Carlson PJ et al (2006) A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Arch Gen Psychiatry 63:856–864
Zhong H, Haddjeri N, Sanchez C (2012) Escitalopram, an antidepressant with an allosteric effect at the serotonin transporter—a review of current understanding of its mechanism of action. Psychopharmacology 219:1–13
Zimmerman M, McGlinchey JB, Posternak MA et al (2006) How should remission from depression be defined? the depressed patient’s perspective. Am J Psychiatry 163:148–150
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Anderson, I.M. (2012). Pharmacological Treatment of Unipolar Depression. In: Cowen, P., Sharp, T., Lau, J. (eds) Behavioral Neurobiology of Depression and Its Treatment. Current Topics in Behavioral Neurosciences, vol 14. Springer, Berlin, Heidelberg. https://doi.org/10.1007/7854_2012_208
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