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Iqbal A, Ložek F, Soto I, Kaur D, Grabicová K, Kuklina I, Randák T, Malinovska V, Buřič M, Kozák P. Effect of psychoactive substances on cardiac and locomotory activity of juvenile marbled crayfish Procambarus virginalis. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2023; 260:115084. [PMID: 37267780 DOI: 10.1016/j.ecoenv.2023.115084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 05/10/2023] [Accepted: 05/27/2023] [Indexed: 06/04/2023]
Abstract
Pharmaceutically active compounds are common and increasing in the aquatic environment. Evidence suggests they have adverse effects on non-target organisms, and they are classified as emerging pollutants for a variety of aquatic organisms. To determine the effects of environmentally relevant levels of psychoactive compounds on non-target organisms, we analyzed cardiac and locomotory activity in early developmental stages of marbled crayfish Procambarus virginalis. Responses to sertraline, methamphetamine, and a mixture of citalopram, oxazepam, sertraline, tramadol, venlafaxine, and methamphetamine at a concentration of 1 µg L-1 of each compound were assessed. On day four of exposure, cardiac activity was recorded for 5 min, and on day eight, locomotory activity was recorded for 15 min. There was a significant increase (p < 0.01) in heart rate in methamphetamine-exposed and Mix-exposed juveniles compared to the unexposed control and there was significant difference (p < 0.01) in proportion of time (activity %) was observed with sertraline-exposed, whereas velocity, and distance moved did not significantly differ (p > 0.05) in exposed and control animals. These findings revealed that low concentrations of chemicals and their mixtures can modify the physiological state of aquatic animals without outward manifestations (activity, distance moved, and velocity). Aquatic animals can be impacted earlier than is visible, but effects can potentially lead to substantial changes in populations and in ecosystem processes. Additional research to investigate chemical combinations, exposure systems, and organism physiological and molecular responses may provide evidence of broad impact of environmental pharmaceuticals.
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Affiliation(s)
- Azeem Iqbal
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic.
| | - Filip Ložek
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
| | - Ismael Soto
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
| | - Davinder Kaur
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
| | - Kateřina Grabicová
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
| | - Iryna Kuklina
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
| | - Tomáš Randák
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
| | - Viktoriia Malinovska
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
| | - Miloš Buřič
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
| | - Pavel Kozák
- University of South Bohemia in České Budějovice, Faculty of Fisheries and Protection of Waters, South Bohemian Research Center of Aquaculture and Biodiversity of Hydrocenoses, Zátiší 728/II, CZ-389 25 Vodňany, Czech Republic
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Madrigal-Bujaidar E, Paniagua-Pérez R, Rendón-Barrón MJ, Morales-González JA, Madrigal-Santillán EO, Álvarez-González I. Investigation of the DNA Damage and Oxidative Effect Induced by Venlafaxine in Mouse Brain and Liver Cells. TOXICS 2022; 10:737. [PMID: 36548570 PMCID: PMC9783611 DOI: 10.3390/toxics10120737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 06/17/2023]
Abstract
Venlafaxine is an antidepressant used worldwide. Therefore, studies to confirm its safe use are mandatory. This report evaluated the drug DNA damage capacity in the brain and liver of ICR mice, and its oxidative effect on DNA, lipids, and proteins, as well as the amount of nitrites, also in the brain and liver. Determinations were made at 2, 6, 12, and 24 h post-treatment, excluding DNA oxidation that was observed at 2 h. The tested doses of venlafaxine were 5, 50, and 250 mg/kg. The results showed DNA damage in the brain with the two more elevated doses of venlafaxine at 2 and 6 h post-treatment and also at 12 h in the liver. The comet assay plus the FPG enzyme showed DNA damage in both organs with all doses. The two high doses increased lipoperoxidation in the two tissues from 6 to 12 h post-administration. Protein oxidation increased with the three doses, mainly from 2 to 12 h, and nitrite content was elevated only with the high dose in the liver. The drug was found to affect both tissues, although it was more pronounced in the liver. Interestingly, DNA oxidative damage was observed even with a dose that corresponds to the therapeutic range. The clinical relevance of these findings awaits further investigations.
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Affiliation(s)
- Eduardo Madrigal-Bujaidar
- Laboratorio de Genética, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Av. Wilfrido Massieu s/n, Zacatenco, Gustavo A. Madero, Ciudad de México 07738, Mexico
| | - Rogelio Paniagua-Pérez
- Instituto Nacional de Rehabilitación, Servicio de Bioquímica. Av., México-Xochimilco 289, Ciudad de México 14389, Mexico
| | - Michael Joshue Rendón-Barrón
- Laboratorio de Genética, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Av. Wilfrido Massieu s/n, Zacatenco, Gustavo A. Madero, Ciudad de México 07738, Mexico
| | - José Antonio Morales-González
- Laboratorio de Medicina de la Conservación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón s/n, Casco de Santo Tomás, Ciudad de México 11340, Mexico
| | - Eduardo O. Madrigal-Santillán
- Laboratorio de Medicina de la Conservación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón s/n, Casco de Santo Tomás, Ciudad de México 11340, Mexico
| | - Isela Álvarez-González
- Laboratorio de Genética, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Av. Wilfrido Massieu s/n, Zacatenco, Gustavo A. Madero, Ciudad de México 07738, Mexico
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Taghizadeh M, Ebrahimi M, Fooladi E, Yoosefian M. Preconcentration and determination of five antidepressants from human milk and urine samples by stir bar filled magnetic ionic liquids using liquid-liquid-liquid microextraction-high performance liquid chromatography. J Sep Sci 2022; 45:1434-1444. [PMID: 35231956 DOI: 10.1002/jssc.202100617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 02/02/2022] [Accepted: 02/09/2022] [Indexed: 11/11/2022]
Abstract
A sensitive and straightforward liquid-liquid-liquid microextraction method was developed to preconcentrate and cleanup antidepressants, including mirtazapine, venlafaxine, escitalopram, fluoxetine, and fluvoxamine, from biological samples before analyzing with high-performance liquid chromatography. The essential novelty of this study is using magnetic ionic liquids as the extraction phase in the lumen of hollow fiber and preparing a liquid magnetic stir bar. In the method, polypropylene hollow fiber was utilized as the permeable membrane for the analyte extraction. Six magnetic ionic liquids consisting of the transition metal and rare earth compounds were synthesized and then injected hollow fiber lumen as acceptor phase to extract the antidepressants. Besides, 3-pentanol as a water-immiscible solvent was impregnated in the hollow fiber wall pores. The effective factors in the method were optimized with the central composition design. The resultant calibration curves were linear over the concentration range of 0.8-400.0 ng mL-1 (R2 ≥ 0.996). The method displayed the proper detection limit (0.11-0.24 ng mL-1 ), the reasonable limit of quantification (≤0.79 ng mL-1 ), wide linear ranges, high preconcentration factors (≥294.3), and suitable relative standard deviation (2.31-5.47%) for measuring antidepressant medications. Analysis of human milk and urine samples showed acceptable recoveries of 96.5-103.8% with excellent relative standard deviations lower than 5.95%. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Mohabat Taghizadeh
- Department of Chemistry, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Mahmoud Ebrahimi
- Department of Chemistry, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Ebrahim Fooladi
- Department of Food Safety and Quality Control, Research Institute of Food Science and Technology (RIFST), Mashhad, Iran
| | - Mehdi Yoosefian
- Department of Nanotechnology, Graduate University of Advanced Technology, Kerman, Iran
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Antidepressant prescriptions have not fully reflected evolving evidence from cumulative network meta-analyses and guideline recommendations. J Clin Epidemiol 2021; 133:14-23. [PMID: 33359320 DOI: 10.1016/j.jclinepi.2020.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/29/2020] [Accepted: 12/17/2020] [Indexed: 02/04/2023]
Abstract
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.
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Luo Y, Chaimani A, Furukawa TA, Kataoka Y, Ogawa Y, Cipriani A, Salanti G. Visualizing the evolution of evidence: Cumulative network meta-analyses of new generation antidepressants in the last 40 years. Res Synth Methods 2021; 12:74-85. [PMID: 32352639 PMCID: PMC7818396 DOI: 10.1002/jrsm.1413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/13/2020] [Accepted: 04/21/2020] [Indexed: 11/21/2022]
Abstract
It is often challenging to present the available evidence in a timely and comprehensible manner. We aimed to visualize the evolution of evidence about antidepressants for depression by conducting cumulative network meta-analyses (NMAs) and to examine whether it could have helped the selection of optimal drugs. We built a Shiny web application that performs and presents cumulative NMAs based on R netmeta. We used a comprehensive dataset of double-blind randomized controlled trials of 21 antidepressants in the acute treatment of major depression. The primary outcomes were efficacy (treatment response) and acceptability (all-cause discontinuation), and treatment effects were summarized via odds ratios. We evaluated the confidence in evidence using the CINeMA (Confidence in Network Meta-Analysis) framework for a series of consecutive NMAs. Users can change several conditions for the analysis, such as the period of synthesis, among the others. We present the league tables and two-dimensional plots that combine efficacy, acceptability and level of confidence in the evidence together, for NMAs conducted in 1990, 1995, 2000, 2005, 2010, and 2016. They reveal that through the past four decades, newly approved drugs often showed initially exaggerated results, which tended to diminish and stabilize after approximately a decade. Over the years, the drugs with relative superiority changed dramatically; but as the evidence network grew larger and better connected, the overall confidence improved. The Shiny app visualizes how evidence evolved over years, emphasizing the need for a careful interpretation of relative effects between drugs, especially for the potentially amplified performance of newly approved drugs. HIGHLIGHTS: Network meta-analysis is considered to be a proper way of demonstrating the available evidence, since it allows comparisons between multiple interventions, and has been proved to be statistically powerful. It is challenging to present the voluminous results of NMA in an efficient and comprehendible manner. Evidence evolution based on the relatively new method NMA has not been investigated yet. The results of NMA should not only include the effects but also the confidence in the evidence, which can help interpret the findings appropriately. Effective use of rapidly developing statistical analysis and presentation tools such as Shiny package in R, may facilitate and simplify the visualization of NMA output. We should stay conservative towards new drugs, as their performance was often shown to be exaggerated initially, and it took time to become stable.
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Affiliation(s)
- Yan Luo
- Department of Health Promotion and Human BehaviorSchool of Public Health in the Graduate School of Medicine, Kyoto UniversityKyotoJapan
| | - Anna Chaimani
- Research Center of Epidemiology and Statistics Sorbonne Paris Cité (CRESS‐UMR1153), INSERM, INRAUniversité de ParisParisFrance
| | - Toshi A. Furukawa
- Department of Health Promotion and Human BehaviorSchool of Public Health in the Graduate School of Medicine, Kyoto UniversityKyotoJapan
| | - Yuki Kataoka
- Hospital Care Research UnitHyogo Prefectural Amagasaki General Medical CenterHyogoJapan
| | - Yusuke Ogawa
- Department of Healthcare EpidemiologySchool of Public Health in the Graduate School of Medicine, Kyoto UniversityKyotoJapan
| | - Andrea Cipriani
- Department of PsychiatryUniversity of Oxford, Oxford Health NHS Foundation Trust, Warneford HospitalOxfordUK
| | - Georgia Salanti
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
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Coppola A, Black S, Johnston S, Endacott R. UK ambulance service resuscitation management of pulseless electrical activity: a systematic review protocol of text and opinion. Br Paramed J 2020; 5:20-25. [PMID: 33456382 PMCID: PMC7783909 DOI: 10.29045/14784726.2020.06.5.1.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Out-of-hospital cardiac arrest patients with pulseless electrical activity are treated by paramedics using basic and advanced life support resuscitation. When resuscitation fails to achieve return of spontaneous circulation, there are limited evidence and national guidelines on when to continue or stop resuscitation. This has led to ambulance services in the United Kingdom developing local guidelines to support paramedics in the resuscitative management of pulseless electrical activity. The content of each guideline is unknown, as is any association between guideline implementation and patient survival. We aim to identify and synthesise local ambulance service guidelines to help improve the consistency of paramedic-led decision-making for the resuscitation of pulseless electrical activity in out-of-hospital cardiac arrest. Methods: A systematic review of text and opinion will be conducted on ambulance service guidelines for resuscitating adult cardiac arrest patients with pulseless electrical activity. Data will be gathered direct from the ambulance service website. The review will be guided by the methods of the Joanna Briggs Institute (JBI). The search strategy will be conducted in three stages: 1) a website search of the 14 ambulance services; 2) a search of the evidence listed in support of the guideline; and 3) an examination of the reference list of documents found in the first and second stages and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Each document will be assessed against the inclusion criteria, and quality of evidence will be assessed using the JBI Critical Appraisal Checklist for Text and Opinion. Data will be extracted using the JBI methods of textual data extraction and a three-stage data synthesis process: 1) extraction of opinion statements; 2) categorisation of statements according to similarity of meaning; and 3) meta-synthesis of statements to create a new collection of findings. Confidence of findings will be assessed using the graded ConQual approach.
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Affiliation(s)
- Alison Coppola
- The University of Plymouth; South Western Ambulance Service NHS Foundation Trust
| | - Sarah Black
- South Western Ambulance Service NHS Foundation Trust
| | - Sasha Johnston
- The University of Plymouth; South Western Ambulance Service NHS Foundation Trust
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Protti M, Mandrioli R, Marasca C, Cavalli A, Serretti A, Mercolini L. New‐generation, non‐SSRI antidepressants: Drug‐drug interactions and therapeutic drug monitoring. Part 2: NaSSAs, NRIs, SNDRIs, MASSAs, NDRIs, and others. Med Res Rev 2020; 40:1794-1832. [DOI: 10.1002/med.21671] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/18/2020] [Accepted: 03/29/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Michele Protti
- Department of Pharmacy and Biotechnology (FaBiT), Pharmaco‐Toxicological Analysis Laboratory (PTA Lab)Alma Mater Studiorum ‐ University of Bologna Bologna Italy
| | - Roberto Mandrioli
- Department for Life Quality Studies (QuVi)Alma Mater Studiorum ‐ University of BolognaRimini Italy
| | - Camilla Marasca
- Department of Pharmacy and Biotechnology (FaBiT), Pharmaco‐Toxicological Analysis Laboratory (PTA Lab)Alma Mater Studiorum ‐ University of Bologna Bologna Italy
- Computational and Chemical BiologyFondazione Istituto Italiano di Tecnologia (IIT) Genoa Italy
| | - Andrea Cavalli
- Department of Pharmacy and Biotechnology (FaBiT), Pharmaco‐Toxicological Analysis Laboratory (PTA Lab)Alma Mater Studiorum ‐ University of Bologna Bologna Italy
- Computational and Chemical BiologyFondazione Istituto Italiano di Tecnologia (IIT) Genoa Italy
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences (DIBINEM)Alma Mater Studiorum ‐ University of Bologna Bologna Italy
| | - Laura Mercolini
- Department of Pharmacy and Biotechnology (FaBiT), Pharmaco‐Toxicological Analysis Laboratory (PTA Lab)Alma Mater Studiorum ‐ University of Bologna Bologna Italy
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Furukawa TA, Cipriani A, Cowen PJ, Leucht S, Egger M, Salanti G. Optimal Dose of Selective Serotonin Reuptake Inhibitors, Venlafaxine, and Mirtazapine in Major Depression: A Systematic Review and Dose-Response Meta-Analysis. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 18:211-219. [PMID: 33343239 PMCID: PMC7587875 DOI: 10.1176/appi.focus.18204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted with permission from Lancet Psychiatry. 2019 Jul;6(7):601-609).
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Luo Y, Kataoka Y, Ostinelli EG, Cipriani A, Furukawa TA. National Prescription Patterns of Antidepressants in the Treatment of Adults With Major Depression in the US Between 1996 and 2015: A Population Representative Survey Based Analysis. Front Psychiatry 2020; 11:35. [PMID: 32116850 PMCID: PMC7033625 DOI: 10.3389/fpsyt.2020.00035] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/13/2020] [Indexed: 01/01/2023] Open
Abstract
Few studies have delineated the real-world, long-term trends of prescription patterns of antidepressants for patients with major depressive disorder (MDD). This study aims to describe their vicissitudes in the nationally representative sample of the US from 1996 to 2015 and explore their characteristics. We used the Medical Expenditure Panel Survey, a nationally representative database of the US population, between 1996 and 2015. We estimated the prevalence of MDD among adults, calculated the proportions of those on antidepressant treatment as well as those on specific drugs through the two decades, and determined their dosages in 2015. We conducted multivariable regression to find possible factors related to their suboptimal prescriptions. The prevalence of adults diagnosed with MDD increased from 6.1% (95% CI, 5.7-6.6%) in 1996 to 10.4% (9.7-11.1%) in 2015. The proportion of patients without any antidepressant therapy decreased but still accounted for 30.6% (28.3-33.1%) in 2015. Sertraline and fluoxetine were among the most frequently prescribed antidepressants throughout the 20 years, while the trend for some new drugs changed dramatically. 16.1% (12.5-20.2%) of patients of MDD on antidepressant monotherapy were prescribed with suboptimal doses in 2015; the risk was lower for those who had higher Body Mass Index (OR 0.94 [0.90-0.99]), longer-term prescriptions (OR 0.92 [0.87-0.97]), and the risk was higher for those who were prescribed with tricyclic antidepressants (OR 11.21 [2.12-59.34], compared with serotonin reuptake inhibitors (SSRIs)), and antidepressants other than SSRIs and serotonin and norepinephrine reuptake inhibitors (OR 4.12 [1.95, 8.73], compared with SSRIs). This study confirmed the growing numbers of patients with MDD and the increase in the antidepressant prescriptions among them. However, the existence of patients without any antidepressant prescriptions or with suboptimal prescriptions and the variable prescription patterns through the decades might suggest some unresolved gaps between evidence and practice.
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Affiliation(s)
- Yan Luo
- Department of Health Promotion and Human Behavior, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuki Kataoka
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Edoardo G Ostinelli
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Andrea Cipriani
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Furukawa TA, Cipriani A, Cowen PJ, Leucht S, Egger M, Salanti G. Optimal dose of selective serotonin reuptake inhibitors, venlafaxine, and mirtazapine in major depression: a systematic review and dose-response meta-analysis. Lancet Psychiatry 2019; 6:601-609. [PMID: 31178367 PMCID: PMC6586944 DOI: 10.1016/s2215-0366(19)30217-2] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 10/31/2022]
Abstract
BACKGROUND Depression is the single largest contributor to non-fatal health loss worldwide. Second-generation antidepressants are the first-line option for pharmacological management of depression. Optimising their use is crucial in reducing the burden of depression; however, debate about their dose dependency and their optimal target dose is ongoing. We have aimed to summarise the currently available best evidence to inform this clinical question. METHODS We did a systematic review and dose-response meta-analysis of double-blind, randomised controlled trials that examined fixed doses of five selective serotonin reuptake inhibitors (SSRIs; citalopram, escitalopram, fluoxetine, paroxetine, and sertraline), venlafaxine, or mirtazapine in the acute treatment of adults (aged 18 years or older) with major depression, identified from the Cochrane Central Register of Controlled Trials, CINAHL, Embase, LILACS, MEDLINE, PsycINFO, AMED, PSYNDEX, websites of drug licensing agencies and pharmaceutical companies, and trial registries. We imposed no language restrictions, and the search was updated until Jan 8, 2016. Doses of SSRIs were converted to fluoxetine equivalents. Trials of antidepressants for patients with depression and a serious concomitant physical illness were excluded. The main outcomes were efficacy (treatment response defined as 50% or greater reduction in depression severity), tolerability (dropouts due to adverse effects), and acceptability (dropouts for any reasons), all after a median of 8 weeks of treatment (range 4-12 weeks). We used a random-effects, dose-response meta-analysis model with flexible splines for SSRIs, venlafaxine, and mirtazapine. FINDINGS 28 554 records were identified through our search (24 524 published and 4030 unpublished records). 561 published and 121 unpublished full-text records were assessed for eligibility, and 77 studies were included (19 364 participants; mean age 42·5 years, SD 11·0; 7156 [60·9%] of 11 749 reported were women). For SSRIs (99 treatment groups), the dose-efficacy curve showed a gradual increase up to doses between 20 mg and 40 mg fluoxetine equivalents, and a flat to decreasing trend through the higher licensed doses up to 80 mg fluoxetine equivalents. Dropouts due to adverse effects increased steeply through the examined range. The relationship between the dose and dropouts for any reason indicated optimal acceptability for the SSRIs in the lower licensed range between 20 mg and 40 mg fluoxetine equivalents. Venlafaxine (16 treatment groups) had an initially increasing dose-efficacy relationship up to around 75-150 mg, followed by a more modest increase, whereas for mirtazapine (11 treatment groups) efficacy increased up to a dose of about 30 mg and then decreased. Both venlafaxine and mirtazapine showed optimal acceptability in the lower range of their licensed dose. These results were robust to several sensitivity analyses. INTERPRETATION For the most commonly used second-generation antidepressants, the lower range of the licensed dose achieves the optimal balance between efficacy, tolerability, and acceptability in the acute treatment of major depression. FUNDING Japan Society for the Promotion of Science, Swiss National Science Foundation, and National Institute for Health Research.
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Affiliation(s)
- Toshi A Furukawa
- Department of Health Promotion and Human Behavior, and Department of Clinical Epidemiology, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.
| | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Stefan Leucht
- Technical University of Munich, School of Medicine, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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