Rational use of antidepressant drugs

Efficacy and mechanism of acupuncture in animal models of depressive-like behaviors: a systematic review and meta-analysis

Background

Many studies have investigated the efficacy of acupuncture in treating depression, but the mechanism of acupuncture for depression is still controversial and there is a lack of meta-analysis of mechanisms. Consequently, we investigated acupuncture's efficacy and mechanism of depression.

Methods

We searched the Cochrane Library, PubMed, EMBASE, Web of Science. The SYRCLE Risk of Bias Tool was used to assess bias risk. Meta-analysis was performed using Stata 15.0 for indicators of depression mechanisms, body weight and behavioral tests.

Results

A total of 22 studies with 497 animals with depressive-like behaviors were included. Meta-analysis showed that acupuncture significantly increased BDNF [SMD = 2.40, 95% CI (1.33, 3.46); I2 = 86.6%], 5-HT [SMD = 2.28, 95% CI (1.08, 3.47); I2 = 87.7%] compared to the control group (p < 0.05), and significantly reduced IL-1β [SMD = -2.33, 95% CI (-3.43, -1.23); I2 = 69.6%], CORT [SMD = -2.81, 95% CI (-4.74, -0.87); I2 = 86.8%] (p < 0.05). Acupuncture improved body weight [SMD = 1.35, 95% CI (0.58, 2.11); I2 = 84.5%], forced swimming test [SMD = -1.89, 95% CI (-2.55, -1.24); I2 = 76.3%], open field test (crossing number [SMD = 3.08, 95% CI (1.98, 4.17); I2 = 86.7%], rearing number [SMD = 2.53, 95% CI (1.49, 3.57); I2 = 87.0%]) (p < 0.05) compared to the control group.

Conclusion

Acupuncture may treat animals of depressive-like behaviors by regulating neurotrophic factors, neurotransmitters, inflammatory cytokines, neuroendocrine system.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023403318, identifier (CRD42023403318).

Symptom Change during Waitlist for Medicated and Nonmedicated Patients with Chronic Depression

INTRODUCTION

Patients seeking psychotherapy often spend time on waitlist (WL), the effect of which is largely unknown. WL patients may forego alternative non-psychotherapeutic assistance and thus do more poorly than had they not been placed on a WL. The course of symptoms might also be influenced by use of antidepressant medication (ADM), an issue that remains unexplored in the literature.

OBJECTIVE

In a naturalistic setting, WL symptom change before inpatient psychotherapy (mean weeks of waiting = 22.6) was assessed in a sample (N = 313) of chronically depressed patients.

METHODS

Using the Beck Depression Inventory-II, patients' symptoms were tracked at assessment, when admitted to treatment (i.e., after WL), at posttreatment and 1-year follow-up. Multilevel growth curve analysis was used to examine waitlist change for the whole sample as well as for ADM users and nonmedicated patients.

RESULTS

Symptoms were reduced significantly from assessment to admittance (Cohen's d = 0.47). Symptoms reduced less for ADM users (d = 0.39) than for nonmedicated patients (d = 0.65).

CONCLUSION

The findings indicate that chronically depressed patients experience a decrease in symptoms during WL, quite likely due to treatment expectations. We discuss whether less symptom improvement for ADM users could be attributed to iatrogenic comorbidity and a higher degree of demoralization in this group.

Associations between Pharmacological Treatment Patterns during the Initial Treatment Period and the Relapse or Recurrence of Anxiety Disorders: A Nationwide Retrospective Cohort Study

Although the importance of proper pharmacological treatment for preventing the relapse/recurrence of anxiety disorders is well known, a real-world data-based study has not been conducted. We aimed to investigate the effect of the initial pharmacological patterns related to continuous treatment and the choice of medication on the relapse/recurrence of anxiety disorders. We used claim data from the Health Insurance Review and Assessment Service, South Korea, of 34,378 adults who received psychiatric medications, including antidepressants, after being newly diagnosed with anxiety disorders. We compared the relapse/recurrence rate in the patients receiving continuous pharmacological treatment with those who discontinued treatment early using Cox's proportional-hazards model. Patients receiving continuous pharmacological treatment experienced a higher risk of relapse/recurrence than those who discontinued treatment. Using three or more antidepressants during the initial treatment period decreased the risk of relapse/recurrence (adjusted hazard ratio (aHR) = 0.229 (0.204-0.256)); however, the combined use of antidepressants from the beginning of treatment increased the risk (aHR = 1.215 (1.131-1.305)). Factors other than continuous pharmacological treatment should be considered to effectively prevent the relapse/recurrence of anxiety disorders. The active use of antidepressants, including switching or adding medications based on progress and frequent follow-up visits during the acute phase, were significantly associated with a reduction in the relapse/recurrence of anxiety disorders.

Potential mechanisms underlying the therapeutic roles of sinisan formula in depression: Based on network pharmacology and molecular docking study

BACKGROUND

The incidence of depression has been increasing globally, which has brought a serious burden to society. Sinisan Formula (SNSF), a well-known formula of traditional Chinese medicine (TCM), has been found to demonstrate an antidepressant effect. However, the therapeutic mechanism of this formula remains unclear. Thus, the present study aimed to explore the mechanism of SNSF in depression through network pharmacology combined with molecular docking methods.

MATERIALS AND METHODS

Bioactive compounds, potential targets of SNSF, and related genes of depression were obtained from public databases. Essential ingredients, potential targets, and signaling pathways were identified using bioinformatics analysis, including protein-protein interaction (PPI), the Gene Ontology (GO), and the Kyoto Encyclopedia of Genes and Genomes (KEGG). Subsequently, Autodock software was further performed for conducting molecular docking to verify the binding ability of active ingredients to targets.

RESULTS

A total of 91 active compounds were successfully identified in SNSF with the use of the comprehensive network pharmacology approach, and they were found to be closely connected to 112 depression-related targets, among which CREB1, NOS3, CASP3, TP53, ESR1, and SLC6A4 might be the main potential targets for the treatment of depression. GO analysis revealed 801 biological processes, 123 molecular functions, and 67 cellular components. KEGG pathway enrichment analysis indicated that neuroactive ligand-receptor interaction, serotonergic synapse pathways, dopaminergic synapse pathways, and GABAergic synapse pathways might have played a role in treating depression. Molecular docking suggested that beta-sitosterol, nobiletin, and 7-methoxy-2-methyl isoflavone bound well to the main potential targets.

CONCLUSION

This study comprehensively illuminated the active ingredients, potential targets, primary pharmacological effects, and relevant mechanism of the SNSF in the treatment of depression. SNSF might exert its antidepressant effects by regulating the signaling pathway of 5-hydroxytryptamine, dopamine, GABA, and neuroactive ligand receptor interactions. Still, more pharmacological experiments are needed for verification.

Post-Marketing Safety Concerns with Esketamine: A Disproportionality Analysis of Spontaneous Reports Submitted to the FDA Adverse Event Reporting System

INTRODUCTION

Esketamine nasal spray received approval for treatment-resistant depression in March 2019.

OBJECTIVE

Using the FDA Adverse Event Reporting System (FAERS) database (March 2019-March 2020), we analysed esketamine-related adverse events (AEs) to detect and characterize relevant safety signals.

METHODS

We used the consolidated case/non-case approach to estimate the reporting odds ratio (ROR) and information component (IC) with relevant confidence intervals (95% CI) for esketamine-related AEs with ≥4 counts. Comparisons between serious and non-serious AEs were performed using non-parametric tests.

RESULTS

The FAERS database contained 962 cases of esketamine-related AEs, with signals detected for several AEs, such as dissociation (ROR = 1,612.64, 95% CI = 1,354.63, 1,919.79; IC = 8.19, 95% CI = 7.96, 8.35), sedation (ROR = 238.46, 95% CI = 202.98, 280.15; IC = 7, 95% CI = 6.75, 7.18), feeling drunk (ROR = 96.17, 95% CI = 61.42, 150.57; IC = 4.84, 95% CI = 4.09, 5.36), suicidal ideation (ROR = 24.03, 95% CI = 18.72, 30.84; IC = 4.31, 95% CI = 3.9, 4.61), and completed suicide (ROR = 5.75, 95% CI = 3.18, 10.41; IC = 2.25, 95% CI = 1.23, 2.94). Signals for suicidal and self-injurious ideation, but not suicide attempt and completed suicide, remained when comparing esketamine to venlafaxine. Females and patients receiving antidepressant polypharmacy, co-medication with mood stabilizers, antipsychotics, benzodiazepines, or somatic medications were more likely to suffer from serious versus non-serious AEs (χ2 = 125.29, p < 0.001, χ2 = 9.08, p = 0.003, χ2 = 8.14, p = 0.004, χ2 = 19.48, p < 0.001, χ2 = 25.62, p < 0.001, and χ2 = 16.79, p < 0.001, respectively).

CONCLUSIONS

Esketamine may carry a clear potential for serious AEs, which deserves urgent clarification by means of further prospective studies.

Acute and Persistent Withdrawal Syndromes Following Discontinuation of Psychotropic Medications

Studies on psychotropic medications decrease, discontinuation, or switch have uncovered withdrawal syndromes. The present overview aimed at analyzing the literature to illustrate withdrawal after decrease, discontinuation, or switch of psychotropic medications based on the drug class (i.e., benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, antidepressants, ketamine, antipsychotics, lithium, mood stabilizers) according to the diagnostic criteria of Chouinard and Chouinard [Psychother Psychosom. 2015;84(2):63-71], which encompass new withdrawal symptoms, rebound symptoms, and persistent post-withdrawal disorders. All these drugs may induce withdrawal syndromes and rebound upon discontinuation, even with slow tapering. However, only selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, and antipsychotics were consistently also associated with persistent post-withdrawal disorders and potential high severity of symptoms, including alterations of clinical course, whereas the distress associated with benzodiazepines discontinuation appears to be short-lived. As a result, the common belief that benzodiazepines should be substituted by medications that cause less dependence such as antidepressants and antipsychotics runs counter the available literature. Ketamine, and probably its derivatives, may be classified as at high risk for dependence and addiction. Because of the lag phase that has taken place between the introduction of a drug into the market and the description of withdrawal symptoms, caution is needed with the use of newer antidepressants and antipsychotics. Within medication classes, alprazolam, lorazepam, triazolam, paroxetine, venlafaxine, fluphenazine, perphenazine, clozapine, and quetiapine are more likely to induce withdrawal. The likelihood of withdrawal manifestations that may be severe and persistent should thus be taken into account in clinical practice and also in children and adolescents.

Mono- and poly-therapy with benzodiazepines or Z-drugs: Results from a tertiary-care Addiction Unit study

BACKGROUND

Using benzodiazepines (BZDs) or Z-drugs in poly-therapy is a critical issue.

OBJECTIVE

Identifying factors influencing the use of BZDs/Z-drugs in poly- vs mono-therapy in patients with or without substance use disorders (SUDs).

METHODS

986 inpatients were analysed. Socio-demographic and clinical variables were collected. BZD/Z-drug doses were compared via the Defined Daily Dose (DDD) and standardized as diazepam dose equivalents. Mann-Whitney, Chi-square, Fisher test, hierarchical multivariate regression analyses were run referring to the whole sample and to subjects with current SUDs, lifetime SUDs, current and lifetime SUDs, non-SUDs.

RESULTS

In the whole sample the variance of being mono- vs poly-therapy users was explained by BZD/Z-drug formulation, DDD, duration of treatment, age of first BZDs/Z-drugs use (ΔR2 = 0.141, p < 0.001). Among those with current SUDs (ΔR2 = 0.278, p = 0.332) or current and lifetime SUDs (ΔR2 = 0.154, p = 0.419), no variables explained the variance of being mono-vs poly-therapy users. Among lifetime SUDs subjects, the variance of being mono- vs poly-therapy users was explained by BZD/Z-drug formulation and age of first BZD/Z-drug use (ΔR2 = 0.275, p < 0.001). Among non-SUDs subjects, the variance of being mono- vs poly-therapy users was explained by DDD and duration of treatment (ΔR2 = 0.162, p = 0.001).

CONCLUSIONS

Tablets, high drug doses, long duration of treatment, and early age of first use were more likely associated to poly- than mono-therapy. This suggests that patients have different clinical features and a pharmacological prescription should be tailored to them also based on the variables here analysed.

The Roles of Serotonin in Neuropsychiatric Disorders

The serotonergic system extends throughout the central nervous system (CNS) and the gastrointestinal (GI) tract. In the CNS, serotonin (5-HT, 5-hydroxytryptamine) modulates a broad spectrum of functions, including mood, cognition, anxiety, learning, memory, reward processing, and sleep. These processes are mediated through 5-HT binding to 5-HT receptors (5-HTRs), are classified into seven distinct groups. Deficits in the serotonergic system can result in various pathological conditions, particularly depression, schizophrenia, mood disorders, and autism. In this review, we outlined the complexity of serotonergic modulation of physiologic and pathologic processes. Moreover, we provided experimental and clinical evidence of 5-HT's involvement in neuropsychiatric disorders and discussed the molecular mechanisms that underlie these illnesses and contribute to the new therapies.

Comparing outcomes in chronic depression following inpatient psychotherapy for patients continuing versus discontinuing antidepressant medication

Research indicates that combination of psychotherapy and antidepressant medication (ADM) provides cumulative effects and thus outperforms monotherapy in treating chronic depression. In this quasi-experimental study, we explored symptom change for patients with chronic depression treated with ADM when presenting for a 12-week psychotherapeutic inpatient treatment programme. We compared outcomes through treatment and follow-up of patients who continued medication with those who discontinued. We also tested possible moderator effects of initial depression severity on change between the groups. Based on prior research, we hypothesized that combination treatment would yield better results (i.e., more reduction in depression). Patients (N = 112) were referred from general practitioners or local secondary health care. Outcome was measured by Beck Depression Inventory-II (BDI-II), and comparisons were carried out using multilevel modelling. Although 35 patients discontinued ADM during treatment, 77 continued. Both continuers and discontinuers had a significant treatment effect that was maintained at 1-year follow-up. There was no difference in outcome between continuers and discontinuers of ADM. Patients with severe depression had significantly more symptom improvement than patients with moderate depression, but depression severity did not affect outcomes across continuers and discontinuers of ADM differently. The results could indicate that patients had developed resistance and/or tolerance to the prophylactic effects of medication and that ADM did not contribute to the reduction of depressive symptoms. The findings may also indicate that psychotherapy alone in some instances can be a viable alternative to continued combined treatment. Clinicians should carefully assess benefits of patients' ongoing use of antidepressant medication when entering psychotherapy.

Effect of group cognitive behavioural therapy on psychological stress and blood glucose in people with type 2 diabetes mellitus: A community-based cluster randomized controlled trial in China

OBJECTIVE

To assess whether group cognitive behavioural therapy (GCBT) delivered by general practitioners reduces anxiety and depression and improves glycaemic levels in adults with type 2 diabetes mellitus.

METHODS

We conducted a community-based cluster randomized controlled trial in adults with type 2 diabetes mellitus from 48 communities in China. Participants received either GCBT plus usual care (UC) or UC only. General practitioners were trained in GCBT before intervention in the intervention group. The primary outcome was glycated haemoglobin (HbA_1c ) concentration. Outcome data were collected from all participants at baseline, 2 months, 6 months and 1 year. The secondary outcomes were depression (Patient Health Questionnaire-9; PHQ-9) and anxiety (General Anxiety Disorder questionnaire; GAD-7).

RESULTS

The GCBT group showed greater improvement in GAD-7 and PHQ-9 scores, respectively, than the UC group after 2 months post-baseline (T = -6.46, p < 0.0001; T = -5.29, p < 0.001), 6 months (T = -4.58, p < 0.001; T = -4.37, p < 0.001) and 1 year post-intervention (T = -3.91, p < 0.001; T = -3.57, p < 0.001). There was no difference in HbA_1c values between the GCBT and UC groups at 2 months while the values were lower in the GCBT group at 6 months and 1 year (T = -6.83, p < 0.001; T = -4.93, p < 0.001, respectively). Subgroup analysis indicated a long-term effect of GCBT only for mild and moderate anxiety and mild depression groups. Similarly, HbA_1c values reduced only in the mild and moderate anxiety and the mild depression groups.

CONCLUSIONS

General practitioners can deliver GCBT interventions. GCBT plus UC is superior to UC for reducing mild/moderate anxiety and depression, and improving glycaemic levels.

TRIAL REGISTRATION

Chinese clinical trials registration (ChiCTR-IOP-16008045).

Efficacy and Harms of Pharmacological Interventions for Anxiety after Traumatic Brain Injury: Systematic Review

After a traumatic brain injury (TBI), many persons experience significant and debilitating problems with anxiety. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for anxiety after TBI. We reviewed studies published in English before July 2020 and included original research on pharmacological interventions for anxiety after TBI in adults ≥16 years of age. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in symptoms of anxiety and occurrence of harms. The secondary outcomes of interest were changes in depression, cognition, quality of life, and participation. Data were summarized in a narrative synthesis, and evidence quality was assessed using the Cochrane Risk of Bias tool. Only a single non-peer-reviewed, randomized controlled trial of 19 male military service members with mild TBI met inclusion criteria. This study found no significant effect of citalopram on anxiety symptoms over a 12-week intervention. The trial was stopped early because of poor recruitment, and much of the study detail was not included in the report. The methodological quality of the study was difficult to assess because of the lack of detail. No recommendations could be drawn from this review. There is a critical need for adequately powered and controlled studies of pharmacological interventions for anxiety after TBI across all severities that examine side-effect profiles and consider issues of comorbidity and effects of long-term pharmacotherapy.

Psychiatric and Psychosomatic Consultation-Liaison Services in General Hospitals: A Systematic Review and Meta-Analysis of Effects on Symptoms of Depression and Anxiety

BACKGROUND

Psychiatric and psychosomatic consultation-liaison services (CL) are important providers of diagnosis and treatment for hospital patients with mental comorbidities and psychological burdens.

OBJECTIVE

To perform a systematic review and meta-analysis investigating the effects of CL on depression and anxiety.

METHODS

Following PRISMA guidelines, a systematic literature search was conducted until 2017. Included were published randomized controlled trials using CL interventions with adults in general hospitals, treatment as usual as control groups, and depression and/or anxiety as outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Level of integration was assessed using the Standard Framework for Levels of Integrated Healthcare. Meta-analyses were performed using random effects models and meta-regression for moderator effects.

RESULTS

We included 38 studies (9,994 patients). Risk of bias was high in 17, unclear in 15, and low in 6 studies. Studies were grouped by type of intervention: brief interventions tailored to the patients (8), interventions based on specific treatment manuals (19), and integrated, collaborative care (11). Studies showed small to medium effects on depression and anxiety. Meta-analyses for depression yielded a small effect (d = -0.19, 95% CI: -0.30 to -0.09) in manual studies and a small effect (d = -0.33, 95% CI: -0.53 to -0.13) in integrated, collaborative care studies, the latter using mostly active control groups with the possibility of traditional consultation.

CONCLUSIONS

CL can provide a helpful first treatment for symptoms of depression and anxiety. Given that especially depressive symptoms in medically ill patients are long-lasting, the results underline the benefit of integrative approaches that respect the complexity of the illness.

The 'patient voice': patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition

BACKGROUND

Stopping antidepressants commonly causes withdrawal symptoms, which can be severe and long-lasting. National Institute for Health and Care Excellence (NICE) guidance has been recently updated to reflect this; however, for many years withdrawal (discontinuation) symptoms were characterised as 'usually mild and self-limiting over a week'. Consequently, withdrawal symptoms might have been misdiagnosed as relapse of an underlying condition, or new onset of another medical illness, but this has never been studied.

METHOD

This paper outlines the themes emerging from 158 respondents to an open invitation to describe the experience of prescribed psychotropic medication withdrawal for petitions sent to British parliaments. The accounts include polypharmacy (mostly antidepressants and benzodiazepines) but we focus on antidepressants because of the relative lack of awareness about their withdrawal effects compared with benzodiazepines. Mixed method analysis was used, including a 'lean thinking' approach to evaluate common failure points.

RESULTS

The themes identified include: a lack of information given to patients about the risk of antidepressant withdrawal; doctors failing to recognise the symptoms of withdrawal; doctors being poorly informed about the best method of tapering prescribed medications; patients being diagnosed with relapse of the underlying condition or medical illnesses other than withdrawal; patients seeking advice outside of mainstream healthcare, including from online forums; and significant effects on functioning for those experiencing withdrawal.

DISCUSSION

Several points for improvement emerge: the need for updating of guidelines to help prescribers recognise antidepressant withdrawal symptoms and to improve informed consent processes; greater availability of non-pharmacological options for managing distress; greater availability of best practice for tapering medications such as antidepressants; and the vital importance of patient feedback. Although the patients captured in this analysis might represent medication withdrawal experiences that are more severe than average, they highlight the current inadequacy of health care systems to recognise and manage prescribed drug withdrawal, and patient feedback in general.

Relapse prevention in recurrent major depressive disorder. A comparison of different treatment options based on clinical experience and a critical review of the literature

BACKGROUND

Reducing the risk of relapses is a critical component of major depressive disorders treatment. Guidelines suggest maintenance with antidepressant drugs in recurrent depression, but this solution has recently been questioned.

OBJECTIVE

The aim of this article is to provide a critical review of the literature of the main treatment options currently available to prevent relapse and recurrence in depression.

METHODS

We compared long-term antidepressant therapy (i.e., indefinite maintenance of antidepressant), intermittent antidepressant therapy (i.e., use of antidepressants mainly limited to the acute phases), use of psychotherapy in the sequential model (i.e., pharmacotherapy in the acute phase and psychotherapy in the residual phase).

RESULTS

We argue that the same solution may not apply to all patients and question the feasibility of a single course of treatment in the setting of complex disorders that are encountered in practice. The clinician should weigh advantages and disadvantages in the individual case.

CONCLUSIONS

The sequential model appears to be particularly indicated in recurrent depression. KEY POINTS Relapse is a major challenge of depressive disorders treatment Treatment options currently available include long-term antidepressants, intermittent antidepressants, addition of psychotherapy to pharmacotherapy in the sequential model Maintenance with antidepressants in recurrent depression has recently been questioned The sequential model appears to be particularly indicated in recurrent depression.

Evidence of new-onset depression among persons with migraine after discontinuing antidepressants

Antidepressants have been hypothesized to cause tardive dysphoria-the delayed development of negative emotional symptoms. We assessed the risk of tardive dysphoria in a cohort of persons with migraine taking anti-migraine antidepressants with no known diagnosis of any mood or anxiety disorder. We included all outpatient encounters in a university hospital system for migraine from January 2008 through October 2018, excluding subjects with prior psychiatric diagnoses. Kaplan-Meier survival curves and multivariable Cox proportional hazards analyses were conducted. 13,048 subjects were included; 1191 took an antidepressant; 402 discontinued an antidepressant. In multivariable analyses examining the first year after exposure, antidepressant use was not significantly associated with risk of a depression, any mood disorder (including depression, mania, and other mood disorders), or anxiety. Antidepressant discontinuation was significantly associated with increased risk of depression, but not any mood disorder or anxiety. Among persons with migraine with no known psychiatric diagnosis, antidepressants did not appear to be associated with indicators of tardive dysphoria. Antidepressant discontinuation, however, was associated with increased risk of a depression diagnosis.

Antidepressants during and after Menopausal Transition: A Systematic Review and Meta-Analysis

To assess the therapeutic benefits of antidepressants in depressive women during and after menopausal transition, PubMed, Cochrane Library, EMBASE and Science Direct were systematically searched from inception to February 1, 2020 for randomized controlled trials examining antidepressants compared to placebo. Primary outcome was change in depressive symptom severity, while secondary outcomes were rates of response/remission rates and dropout/discontinuation due to adverse events. Seven trials involving 1,676 participants (mean age = 52.6 years) showed significant improvement in depressive symptoms (k = 7, Hedges’ g = 0.44, 95% confidence interval (CI) = 0.32 to 0.57, p < 0.001) relative to that in controls. Furthermore, response (k = 3, odds ratio (OR) = 2.53, 95% CI = 1.24 to 5.15, p = 0.01) and remission (k = 3, OR = 1.84, 95% CI = 1.32 to 2.57, p < 0.001) rates were significantly higher in antidepressant-treated groups compared to those with controls. Although dropout rates did not differ between antidepressant and control groups (k = 6, OR = 0.93, 95% CI = 0.70 to 1.26, p = 0.68), the rate of discontinuation due to adverse events was significantly higher in antidepressant-treated groups (k = 6, OR = 0.55, 95% CI = 0.35 to 0.86, p = 0.01). Subgroup analysis indicated that antidepressants were also efficacious for depressive symptoms in those without diagnosis of MDD. The results demonstrated that antidepressants were efficacious for women with depressive syndromes during and after menopausal transition but associated with a higher risk of discontinuation due to adverse events.

How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding

The aim of this article is to discuss the validity of relapse prevention trials and the issue of withdrawal confounding in these trials. Recommendations for long-term antidepressant treatment are based almost exclusively on discontinuation trials. In these relapse prevention trials, participants with remitted depression are randomised either to have the antidepressant abruptly discontinued and replaced by inert placebo or to continue active treatment. The drug-placebo difference in relapse rates at the end of the maintenance phase is then interpreted as a prophylactic drug effect. These trials consistently produce remarkable benefits for maintenance treatment. However, the internal validity of this trial protocol is compromised, as research has shown that abruptly stopping antidepressants can cause severe withdrawal reactions that lead to (or manifest as) depression relapses. That is, there is substantial withdrawal confounding in discontinuation trials, which renders their findings uninterpretable. It is not clear to what degree the drug-placebo separation in relapse prevention (discontinuation) trials is due to withdrawal reactions, but various estimations suggest that it is presumably the majority. A review of findings based on other methodologies, including real-world long-term effectiveness trials like STAR*D and various naturalistic cohort studies, do not indicate that antidepressants have considerable prophylactic effects. As absence of evidence does not imply evidence of absence, no definitive conclusions can be drawn from the literature. To enable a thorough risk-benefit evaluation, real-world effectiveness trials should not only focus on relapse prevention, but also assess antidepressants' long-term effects on social functioning and quality of life. Thus far, reliable long-term data on these outcome domains are lacking.

A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology

Using Richardson and Davidson's model and the sciences of pharmacokinetics and clinical pharmacopsychology, this article reviewed the: (1) poor life expectancy associated with treatment-resistant schizophrenia (TRS), which may be improved in patients who adhere to clozapine; (2) findings that clozapine is the best treatment for TRS (according to efficacy, effectiveness and well-being); and (3) potential for clozapine to cause vulnerabilities, including potentially lethal adverse drug reactions such as agranulocytosis, pneumonia, and myocarditis. Rational use requires: (1) modification of the clozapine package insert worldwide to include lower doses for Asians and to avoid the lethality associated with pneumonia, (2) the use of clozapine levels for personalizing dosing, and (3) the use of slow and personalized titration. This may make clozapine as safe as possible and contribute to increased life expectancy and well-being. In the absence of data on COVID-19 in clozapine patients, clozapine possibly impairs immunological mechanisms and may increase pneumonia risk in infected patients. Psychiatrists should call their clozapine patients and families and explain to them that if the patient develops fever or flu-like symptoms, the psychiatrist should be called and should consider halving the clozapine dose. If the patient is hospitalized with pneumonia, the treating physician needs to assess for symptoms of clozapine intoxication since halving the dose may not be enough for all patients; consider decreasing it to one-third or even stopping it. Once the signs of inflammation and fever have disappeared, the clozapine dose can be slowly increased to the prior dosage level.

Well-Being Therapy in Anxiety Disorders

In almost all treatments for prevalent psychiatric conditions, particular attention has been devoted to stress and its consequences; this has led to an involuntary and unavoidable reinforcement of negative aspects of life. Because of the important influence of individual and cultural influences on positive health, well-being is a challenge from a clinical and scientific perspective and interventions aimed at enhancing it represent an area of growing interest for the future of clinical practice and research. Well-being therapy (WBT) is a short-term psychotherapeutic strategy aimed at enhancing well-being based on the model originally developed in 1958 by Marie Jahoda. It emphasizes self-observation, with the use of a structured diary, interaction between patients and therapists, and homework. WBT may be used as the only therapeutic strategy or in sequential combination with other psychotherapeutic strategies, mainly cognitive behavioral therapy. WBT can be differentiated from positive interventions based on several features which are described in detail in the present chapter. We also report the clinical use of WBT in the treatment of anxiety disorders, mainly generalized anxiety disorder, panic disorder, and agoraphobia. Potential further clinical application of WBT is withdrawal after antidepressants discontinuation and side effects during long-term antidepressant treatment.

Trends in Antidepressant Use and Expenditure in Six Major Cities in China From 2013 to 2018

The objective of this study was to investigate the current status and trends in antidepressant use and expenditure in China from 2013 to 2018. The study had a retrospective design based on prescribing data on antidepressant drugs, which was sourced from the Hospital Prescription Analysis Cooperative Project. The trends in hospital visits and corresponding expenditure on antidepressant drugs were examined. Subgroup analyses were carried out by sex, age, and drug class. A total of 1,795,230 outpatient prescriptions were collected from 79 hospitals in six major cities in China. Hospital visits with antidepressant prescriptions rose significantly from 244,626 in 2013 to 348,718 in 2018, reflecting a 42.6% increase (P < 0.05). The antidepressant expenditure also rose, increasing from 48.0 million Chinese yuan in 2013 to 64.8 million Chinese yuan in 2018. There were approximately 1.6 times more antidepressant prescriptions written for women than for men. The most frequent age category for antidepressant prescriptions was 45-64 years. The most commonly prescribed antidepressants were selective serotonin reuptake inhibitors (N06AB) and other antidepressants (N06AX), whereas tricyclic antidepressants (N06AA) accounted for only a small part of the total antidepressant prescriptions. Flupentixol/melitracen and escitalopram were the most frequently prescribed antidepressants. Antidepressant prescribing rates continue to increase in China, although the prescribing patterns have changed over the past few years. The wide use of expensive antidepressants and those with weak clinical evidence raises concerns regarding the rational use of antidepressants. This study provides a basis for future stewardship by the government and medical institutions.

May antidepressant drugs worsen the conditions they are supposed to treat? The clinical foundations of the oppositional model of tolerance

In recent years there has been a considerable debate on antidepressant drugs. Continued drug treatment with antidepressant medications may stimulate processes that run counter to the initial acute effects of a drug. The oppositional model of tolerance may explain loss of treatment efficacy during maintenance treatment and the fact that some side effects tend to occur only after a certain time. These processes may also direct the illness into a treatment-unresponsive course, including manifestations of bipolar disorder or paradoxical reactions. When drug treatment ends, oppositional processes no longer encounter resistance, resulting in potential onset of new withdrawal symptoms, persistent post-withdrawal disorders, hypomania, and resistance to treatment if it is reinstituted. In all these cases, antidepressant medications may constitute a form of iatrogenic comorbidity, which increases chronicity and vulnerability to depressive episodes. Antidepressant medications are essential drugs for the treatment of major depressive episodes. They are less likely, however, to provide protection for relapse prevention. Current prescription practices need to be reformulated in light of consideration of vulnerabilities and adverse effects of treatment. The oppositional model of tolerance provides a conceptual framework for weighing all these elements in the individual case. The model does not appear to apply to all patients who undergo treatment with AD, but only to a part of them. Studying the variables that are associated with such occurrence in certain patients and not in others would be one of the most important tasks of current therapeutic research. Current diagnostic systems in psychiatry do not consider the iatrogenic components of psychopathology, and can be applied to only patients who are drug free. They are suited for a patient who no longer exists: most of the cases that are seen in psychiatric clinical practice receive psychotropic drugs and such treatment is likely to affect prognosis and treatment choices.

Evidence-based practice: a comparison of International Clinical Practice Guidelines and current research on physical activity for mild to moderate depression

In 2016, the U.S. Preventive Services Task Force recommended routine depression screening for individuals aged 13 and above. Questionnaire-based screening will likely increase treatment in patients with milder symptoms. Although professional groups who develop clinical practice guidelines recognize the importance of considering the risks and benefits of interventions, no official mandate exists for a stepped-care approach. Physical activity warrants increased consideration in guidelines, given the optimal risk/benefit profile and the increasing evidence of efficacy for the treatment and prevention of depression. The aim of the current study was to evaluate clinical practice guidelines for the treatment of major depressive disorder, specifically the recommendation of physical activity and adherence to a stepped-care approach. Authors searched three databases to identify treatment guidelines for depression. Guidelines were reviewed on the following domains regarding recommendation of physical activity: (a) front-line intervention, (b) explicit but not front-line recommendation, (c) inexplicit recommendation, (d) no mention, (e) adherence to a stepped-care approach, and (f) presentation of empirical support for their recommendation. Seventeen guidelines met inclusion criteria. Four guidelines recommended physical activity as a front-line intervention, two did not mention physical activity, eleven made some mention of physical activity, seven presented evidence to support their recommendation, and seven employed a stepped-care approach. The majority of guidelines did not use a stepped-care approach and varied greatly in their inclusion of physical activity as a recommended intervention for mild to moderate depression. Implications for practice, research, and policy are discussed.

Withdrawal Confounding in Randomized Controlled Trials of Antipsychotic, Antidepressant, and Stimulant Drugs, 2000-2017

BACKGROUND

Results of relapse prevention randomized controlled trials (RCTs) which discontinue psychotropic drug treatment from some participants may be confounded by drug withdrawal symptoms. We test for the confound by calculating whether ≥50% of the difference in relapse risk between drug-discontinued and drug-maintained groups is present at discontinuation time points (DCTs) with "short" and "long" assumptions regarding onset and duration of withdrawal symptoms.

METHODS

In eligible RCTs of antidepressants, antipsychotics, and stimulants from 2000 to 2017 (n = 30) selected from a systematic review, differences in relapse risk were examined by arithmetic and graphical comparison of mean behavioral scores or survival plots.

RESULTS

Only 14 studies (46.6%) with 15 analyses of relapse risk provided sufficient data. Under short and long DCTs, 9 of 13 (69.2%) and 7 of 9 (77.8%) interpretable analyses, respectively, suggested a withdrawal confound. The proportion of endpoint placebo-maintenance group difference present by the DCT averaged 69.1% (range, 58.7-148.0%, n = 13) for short DCT assumptions, and 79.0% (range, 51.5-183.3%, n = 9) under long DCTs. One study (3.33%) controlled for withdraw al effects, and 1 yielded inconclusive results.

CONCLUSIONS

These results support suggestions that withdrawal symptoms confound the results of relapse prevention RCTs. Accounting for such symptoms in RCTs is an ethical, scientific, and clinical imperative. Justifications for relapse prevention RCTs employing a discontinuation procedure require more scrutiny.

Antidepressant Use During Acute Inpatient Care Is Associated With an Increased Risk of Psychiatric Rehospitalisation Over a 12-Month Follow-Up After Discharge

Background: Some evidence suggests that antidepressants may relate to poor outcomes in depression. The aim of this study was, therefore, to examine, whether antidepressant use may worsen the long-term outcome in real-world psychiatric patients with both primarily affective and non-affective mental disorders. Methods: Based on a total of n = 151 inpatients with a mixed range of diagnoses enrolled at two psychiatric hospitals in Zurich, Switzerland, matched pairs of n = 45 antidepressant users and n = 45 non-users were selected via nearest neighbor propensity score matching. Pairs were matched according to 14 clinically relevant covariates assessing psychosocial impairments, functioning deficits and illness severity. The two outcomes of interest were the number and total duration of all rehospitalisations over a 12-month follow-up after discharge from the hospital based on the official clinical registry. Results: Altogether 35.6% of antidepressant users were rehospitalised at least once, as compared to 22.2% in matched non-users. Two or more rehospitalisations occurred in 22.2% of antidepressant users but only in 2.2% of non-users. In antidepressant users, the mean total duration of rehospitalisations was 22.22 days, as compared to 8.51 in matched non-users. According to Poisson regression analyses, antidepressant use during acute inpatient care prospectively relates to both a higher risk (incidence rate ratio [IRR] = 3.64, 95% confidence interval [95%-CI] = 1.71-7.75, p = 0.001) and a longer duration (IRR = 2.61, 95%-CI = 1.01-6.79, p = 0.049) of subsequent rehospitalisations. These findings were consistently replicated when traditional multivariable regression analysis was applied to the full sample. Findings also replicated when patients with affective and non-affective disorders were analyzed separately. Conclusions: Our findings raise the possibility that, in the long-term, antidepressants may impair recovery and increase the risk of rehospitalisation in patients with both primarily affective and non-affective disorders. More work is required to explore possible aetiopathological pathways leading to psychiatric rehospitalisation.

Long-Term and Short-Term Antidepressant Use in General Practice: Data from a Large Cohort in the Netherlands

BACKGROUND

Antidepressant use is highly prevalent. Research has mainly focused on efficacy during short periods of use for depression and anxiety. There is a relative paucity of data regarding the frequency of long-term use.

METHODS

To determine the prevalence and possible increase of long-term use of antidepressants over recent years, we analyzed routine general practice care data in a large cohort of patients (n = 156,620) in and around Amsterdam, The Netherlands. Additionally, predictors of long-term use were studied.

RESULTS

Prevalence of long-term use of antidepressants is substantial, and such use appears to be increasing: 30.3% of use was long-term over the period 1995-2005 compared to 43.7% for the period 2005-2015. Higher age, a registered diagnosis of anxiety or depression, and the use of SSRIs or SNRIs were associated with long-term use in multivariate analysis. In addition, specific antidepressants were differentially associated with long-term use.

CONCLUSIONS

Long-term antidepressant use is substantial and appears to be on the rise. Awareness of this phenomenon should be increased, such use should be prevented when possible, and reasons for long-term use need to be examined.

Failure to Respond after Reinstatement of Antidepressant Medication: A Systematic Review

BACKGROUND

Following remission of an anxiety disorder or a depressive disorder, antidepressants are frequently discontinued and in the case of symptom occurrence reinstated. Reinstatement of antidepressants seems less effective in some patients, but an overview is lacking. This systematic review aimed to provide insight into the magnitude and risk factors of response failure after reinstatement of antidepressants in patients with anxiety disorders, depressive disorders, obsessive-compulsive disorder (OCD), or posttraumatic stress disorder (PTSD).

METHOD

PubMed, Embase, and trial registers were systematically searched for studies in which patients: (1) had an anxiety disorder, a depressive disorder, OCD, or PTSD and (2) experienced failure to respond after reinstatement of a previously effective antidepressant.

RESULTS

Ten studies reported failure to respond following antidepressant reinstatement. The phenomenon was observed in 16.5% of patients with a depressive disorder, OCD, and social phobia and occurred in all common classes of antidepressants. The range of response failure was broad, varying between 3.8 and 42.9% across studies. No risk factors for failure to respond were investigated. The overall study quality was limited.

CONCLUSION

Research investigating response failure is scarce and the study quality limited. Response failure occurred in a substantial minority of patients. Contributors to the relevance of this phenomenon are the prevalence of the investigated disorders, the number of patients being treated with antidepressants, and the occurrence of response failure for all common classes of antidepressants. This systematic review highlights the need for studies systematically investigating this phenomenon and associated risk factors.

Dose Escalation of Antidepressants in Unipolar Depression: A Meta-Analysis of Double-Blind, Randomized Controlled Trials

BACKGROUND

As many patients with unipolar depression do not respond sufficiently to initial antidepressant monotherapy, a dose increase of the current administered antidepressant (dose escalation, high-dose treatment) is frequently carried out as next treatment measure.

METHODS

We conducted a meta-analysis which included all double-blind randomized controlled trials (RCTs) comparing a dose increase of antidepressants directly to continuation of standard-dose treatment in unipolar depressive patients who were non- responders to standard-dose pharmacotherapy. A mean change in the Hamilton Rating Scale for Depression (HAM-D) total score was the primary outcome. Secondary outcomes were response rates and discontinuation rates due to any reason, inefficacy, and adverse effects. Hedges g and risk ratios were calculated as effect sizes.

RESULTS

Seven double-blind RCTs (8 study arms) representing 1,208 participants were included. Fluoxetine (N [number of studies] = 2, n [number of patients] = 448), sertraline (N = 2, n = 272), paroxetine (N = 2, n = 146), duloxetine (N = 1, n = 255), and maprotiline (N = 1, n = 87) were investigated. Dose escalation was not more efficacious in HAM-D total score reduction than maintaining standard-dose treatment, neither for the pooled antidepressant group (N = 7, n = 999; Hedges g = -0.04, 95% CI: -0.20 to 0.12; p = 0.63) nor the individual antidepressants. No differences could be determined for response rates, all-cause discontinuation, and drop-outs due to inefficacy. Significantly more patients in the dose escalation group dropped out due to adverse effects than in the standard-dose continuation group. The metaregressions indicate no influence of baseline symptom severity or amounts of dose increments on effect sizes.

CONCLUSIONS

According to our meta-analytic findings, dose escalation after initial non-response to standard-dose pharmacotherapy cannot be regarded as general evidence-based treatment option in unipolar depression.

The Mortality and Myocardial Effects of Antidepressants Are Moderated by Preexisting Cardiovascular Disease: A Meta-Analysis

BACKGROUND

Antidepressants (ADs) are commonly prescribed medications, but their long-term health effects are debated. ADs disrupt multiple adaptive processes regulated by evolutionarily ancient biochemicals, potentially increasing mortality. However, many ADs also have anticlotting properties that can be efficacious in treating cardiovascular disease. We conducted a meta-analysis assessing the effects of ADs on all-cause mortality and cardiovascular events in general-population and cardiovascular-patient samples.

METHODS

Two reviewers independently assessed articles from PubMed, EMBASE, and Google Scholar for AD-related mortality controlling for depression and other comorbidities. From these articles, we extracted information about cardiovascular events, cardiovascular risk status, and AD class. We conducted mixed-effect meta-analyses testing sample type and AD class as moderators of all-cause mortality and new cardiovascular events.

RESULTS

Seventeen studies met our search criteria. Sample type consistently moderated health risks. In general-population samples, AD use increased the risks of mortality (HR = 1.33, 95% CI: 1.14-1.55) and new cardiovascular events (HR = 1.14, 95% CI: 1.08-1.21). In cardiovascular patients, AD use did not significantly affect risks. AD class also moderated mortality, but the serotonin reuptake inhibitors were not significantly different from tricyclic ADs (TCAs) (HR = 1.10, 95% CI: 0.93-1.31, p = 0.27). Only "other ADs" were differentiable from TCAs (HR = 1.35, 95% CI: 1.08-1.69). Mortality risk estimates increased when we analyzed the subset of studies controlling for premedication depression, suggesting the absence of confounding by indication.

CONCLUSIONS

The results support the hypothesis that ADs are harmful in the general population but less harmful in cardiovascular patients.

Effectiveness of Supported Self-Help in Recurrent Depression: A Randomized Controlled Trial in Primary Care

BACKGROUND

The burden and economic consequences of depression are high, mostly due to its recurrent nature. Due to current budget and time restraints, a preventive, low- cost, accessible minimal intervention is much needed. In this study, we evaluated the effectiveness of a supported self-help preventive cognitive therapy (S-PCT) added to treatment as usual (TAU) in primary care, compared to TAU alone.

METHODS

We conducted a randomized controlled trial among 248 patients with a history of depression, currently in full or partial remission or recovery. Participants were randomized to TAU augmented with S-PCT (n = 124) or TAU alone (n = 124). S-PCT consisted of an 8-week self-help intervention, supported by weekly telephone guidance by a counselor. The intervention included a self-help book that could be read at home. The primary outcome was the incidence of relapse or recurrence and was assessed over the telephone by the Structured Clinical Interview for DSM-IV axis 1 disorders. Participants were observed for 12 months. Secondary outcomes were depressive symptoms, quality of life (EQ-5D and SF-12), comorbid psychopathology, and self-efficacy. These secondary outcomes were assessed by digital questionnaires.

RESULTS

In the S-PCT group, 44 participants (35.5%) experienced a relapse or recurrence, compared to 62 participants (50.0%) in the TAU group (incidence rate ratio = 0.71, 95% CI 0.52-0.97; risk difference = 14, 95% CI 2-24, number needed to treat = 7). Compared to the TAU group, the S-PCT group showed a significant reduction in depressive symptoms over 12 months (mean difference -2.18; 95% CI -3.09 to -1.27) and a significant increase in quality of life (EQ-5D) (mean difference 0.04; 95% CI 0.004-0.08). S-PCT had no effect on comorbid psychopathology, self-efficacy, and quality of life based on the SF-12.

CONCLUSIONS

A supported self-help preventive cognitive therapy, guided by a counselor in primary care, proved to be effective in reducing the burden of recurrent depression.

What psychologists need to know about psychotropic medications

Despite the fact that today most of the patients with psychological disturbances assume some form of psychotropic drug treatment, clinical psychologists may have little familiarity with psychopharmacology and are substantially unaware of subtle and yet pervasive potential effects of medications in clinical presentations. In their training, psychologists are generally exposed, at best, to some general principles of drug action. Standard psychopharmacology textbooks tend to omit the subtle psychological changes that may occur during psychotropic drug treatment. Clinical pharmacopsychology consists of the application of clinical psychology to the full understanding of pharmacological effects. The domains of clinical pharmacopsychology encompass the clinical benefits of psychotropic drugs, the characteristics that predict responsiveness to treatment, the vulnerabilities induced by treatment (side effects, behavioural toxicity, iatrogenic comorbidity), and the interactions between drug treatment and psychological variables. The DSM-5 refers to a patient population that no longer exists: subjects who display various manifestations of psychological distress who do not receive any form of drug treatment for it. Any type of psychotropic drug treatment, particularly after long-term use, may increase the risk of experiencing additional psychopathological problems that do not necessarily subside with discontinuation of the drug. The changes may be persistent and not limited to a short phase, such as in the case of withdrawal reactions, and cannot be subsumed under the generic rubrics of adverse events or side effects.

Antipsychotic augmentation for major depressive disorder: A review of clinical practice guidelines

Clinical Practice Guidelines (CPGs) are seen as the gold standard of evidence-based care. Because of their influence, these guidelines can have profound legal and economic effects. Despite their proliferation and influence, the trustworthiness and quality of guidelines have been seriously questioned and they have been implicated as drivers of overtreatment. In the U.S, augmentation with second generation antipsychotics (SGAs) is becoming an increasingly common strategy for treating major depressive disorder (MDD) when initial antidepressant treatment does not result in remission of symptoms. However, there is debate about the evidence for augmentation and whether this strategy is a form of overtreatment. We conducted a systematic search to identify treatment guidelines for MDD. Fourteen international guidelines met inclusion criteria and we reviewed them to determine: 1) if augmentation with SGAs was recommended for patients who did not respond to antidepressant medication; 2) what evidence was cited for the recommendation for or against augmentation; 3) the extent to which the guidelines addressed risk/benefit concerns when making their recommendations. There was significant variation among the CPGs regarding the recommendation to augment with antipsychotic medication for Major Depressive Disorder. Seven guidelines explicitly recommended augmentation with antipsychotics; 1 guideline reviewed the evidence but neither recommended for nor against; 1 guideline did not make a clear recommendation; 2 guidelines explicitly recommended against augmentation; and 3 guidelines did not address augmentation with antipsychotics as a potential treatment strategy. There was wide variation in terms of attention to risk/benefit issues and to the conditions under which augmentation should be considered. The results are discussed in terms of the implications for risk management and informed consent practices.

Current Psychosomatic Practice

Psychosomatic research has advanced over the past decades in dealing with complex biopsychosocial phenomena and may provide new effective modalities of patient care. Among psychosocial variables affecting individual vulnerability, course, and outcome of any medical disease, the role of chronic stress (allostatic load/overload) has emerged as a crucial factor. Assessment strategies include the Diagnostic Criteria for Psychosomatic Research. They are presented here in an updated version based on insights derived from studies carried out so far and encompass allostatic overload, type A behavior, alexithymia, the spectrum of maladaptive illness behavior, demoralization, irritable mood, and somatic symptoms secondary to a psychiatric disorder. Macroanalysis is a helpful tool for identifying the relationships between biological and psychosocial variables and the individual targets for medical intervention. The personalized and holistic approach to the patient includes integration of medical and psychological therapies in all phases of illness. In this respect, the development of a new psychotherapeutic modality, Well-Being Therapy, seems to be promising. The growth of subspecialties, such as psychooncology and psychodermatology, drives towards the multidisciplinary organization of health care to overcome artificial boundaries. There have been major transformations in health care needs in the past decades. From psychosomatic medicine, a land of innovative hypotheses and trends, many indications for changes in the current practice of medicine are now at hand. The aim of this critical review is to outline current and potential clinical applications of psychosomatic methods.

The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature

Newer generation antidepressant drugs (ADs) are widely used as the first line of treatment for major depressive disorders and are considered to be safer than tricyclic agents. In this critical review, we evaluated the literature on adverse events, tolerability and safety of selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, bupropion, mirtazapine, trazodone, agomelatine, vilazodone, levomilnacipran and vortioxetine. Several side effects are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass gastrointestinal symptoms (nausea, diarrhea, gastric bleeding, dyspepsia), hepatotoxicity, weight gain and metabolic abnormalities, cardiovascular disturbances (heart rate, QT interval prolongation, hypertension, orthostatic hypotension), genitourinary symptoms (urinary retention, incontinence), sexual dysfunction, hyponatremia, osteoporosis and risk of fractures, bleeding, central nervous system disturbances (lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances), sweating, sleep disturbances, affective disturbances (apathy, switches, paradoxical effects), ophthalmic manifestations (glaucoma, cataract) and hyperprolactinemia. At times, such adverse events may persist after drug discontinuation, yielding iatrogenic comorbidity. Other areas of concern involve suicidality, safety in overdose, discontinuation syndromes, risks during pregnancy and breast feeding, as well as risk of malignancies. Thus, the rational selection of ADs should consider the potential benefits and risks, likelihood of responsiveness to the treatment option and vulnerability to adverse events. The findings of this review should alert the physician to carefully review the appropriateness of AD prescription on an individual basis and to consider alternative treatments if available.

Cognitive Behavioral Therapy for Patients with Social Anxiety Disorder Who Remain Symptomatic following Antidepressant Treatment: A Randomized, Assessor-Blinded, Controlled Trial

BACKGROUND

Although antidepressants are still a commonly used treatment for social anxiety disorder (SAD), a significant proportion of patients fail to remit following antidepressants. However, no standard approach has been established for managing such patients. This study aimed to examine the effectiveness of cognitive behavioral therapy (CBT) as an adjunct to usual care (UC) compared with UC alone in SAD patients who remain symptomatic following antidepressant treatment.

METHODS

This was a prospective randomized open-blinded end-point study with two parallel groups (CBT + UC, and UC alone, both for 16 weeks) conducted from June 2012 to March 2014. SAD patients who remain symptomatic following antidepressant treatment were recruited, and a total sample size of 42 was set based on pilot results.

RESULTS

Patients were randomly allocated to CBT + UC (n = 21) or UC alone (n = 21). After 16 weeks, adjusted mean reduction in the Liebowitz Social Anxiety Scale from baseline for CBT + UC and UC alone was -40.87 and 0.68, respectively; the between-group difference was -41.55 (-53.68 to -29.42, p < 0.0001). Response rates were 85.7 and 10.0% for CBT + UC and UC alone, respectively (p < 0.0001). The corresponding remission rates were 47.6 and 0.0%, respectively (p = 0.0005). Significant differences were also found in favor of CBT + UC for social anxiety symptoms, depressive symptoms, and functional impairment.

CONCLUSIONS

Our results suggest that in SAD patients who have been ineffectively treated with antidepressants, CBT is an effective treatment adjunct to UC over 16 weeks in reducing social anxiety and related symptoms.

Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder

BACKGROUND

It is unclear whether antidepressants can prevent suicides or suicide attempts, particularly during long-term use.

METHODS

We carried out a comprehensive review of long-term studies of antidepressants (relapse prevention). Sources were obtained from 5 review articles and by searches of MEDLINE, PubMed Central and a hand search of bibliographies. We meta-analyzed placebo-controlled antidepressant RCTs of at least 3 months' duration and calculated suicide and suicide attempt incidence rates, incidence rate ratios and Peto odds ratios (ORs).

RESULTS

Out of 807 studies screened 29 were included, covering 6,934 patients (5,529 patient-years). In total, 1.45 suicides and 2.76 suicide attempts per 1,000 patient-years were reported. Seven out of 8 suicides and 13 out of 14 suicide attempts occurred in antidepressant arms, resulting in incidence rate ratios of 5.03 (0.78-114.1; p = 0.102) for suicides and of 9.02 (1.58-193.6; p = 0.007) for suicide attempts. Peto ORs were 2.6 (0.6-11.2; nonsignificant) and 3.4 (1.1-11.0; p = 0.04), respectively. Dropouts due to unknown reasons were similar in the antidepressant and placebo arms (9.6 vs. 9.9%). The majority of suicides and suicide attempts originated from 1 study, accounting for a fifth of all patient-years in this meta-analysis. Leaving out this study resulted in a nonsignificant incidence rate ratio for suicide attempts of 3.83 (0.53-91.01).

CONCLUSIONS

Therapists should be aware of the lack of proof from RCTs that antidepressants prevent suicides and suicide attempts. We cannot conclude with certainty whether antidepressants increase the risk for suicide or suicide attempts. Researchers must report all suicides and suicide attempts in RCTs.

Methodological Flaws, Conflicts of Interest, and Scientific Fallacies: Implications for the Evaluation of Antidepressants' Efficacy and Harm

BACKGROUND

In current psychiatric practice, antidepressants are widely and with ever-increasing frequency prescribed to patients. However, several scientific biases obfuscate estimates of antidepressants' efficacy and harm, and these are barely recognized in treatment guidelines. The aim of this mini-review is to critically evaluate the efficacy and harm of antidepressants for acute and maintenance treatment with respect to systematic biases related to industry funding and trial methodology.

METHODS

Narrative review based on a comprehensive search of the literature.

RESULTS

It is shown that the pooled efficacy of antidepressants is weak and below the threshold of a minimally clinically important change once publication and reporting biases are considered. Moreover, the small mean difference in symptom reductions relative to placebo is possibly attributable to observer effects in unblinded assessors and patient expectancies. With respect to trial dropout rates, a hard outcome not subjected to observer bias, no difference was observed between antidepressants and placebo. The discontinuation trials on the efficacy of antidepressants in maintenance therapy are systematically flawed, because in these studies, spontaneous remitters are excluded, whereas half of all patients who remitted on antidepressants are abruptly switched to placebo. This can cause a severe withdrawal syndrome that is easily misdiagnosed as a relapse when assessed on subjective symptom rating scales. In accordance, the findings of naturalistic long-term studies suggest that maintenance therapy has no clear benefit, and non-drug users do not show increased recurrence rates. Moreover, a growing body of evidence from hundreds of randomized controlled trials suggests that antidepressants cause suicidality, but this risk is underestimated because data from industry-funded trials are systematically flawed. Unselected, population-wide observational studies indicate that depressive patients who use antidepressants are at an increased risk of suicide and that they have a higher rate of all-cause mortality than matched controls.

CONCLUSION

The strong reliance on industry-funded research results in an uncritical approval of antidepressants. Due to several flaws such as publication and reporting bias, unblinding of outcome assessors, concealment and recoding of serious adverse events, the efficacy of antidepressants is systematically overestimated, and harm is systematically underestimated. Therefore, I conclude that antidepressants are largely ineffective and potentially harmful.