Direct comparison of tricyclic and serotonin-reuptake inhibitor antidepressants in randomized head-to-head trials in acute major depression: Systematic review and meta-analysis

Escitalopram versus other antidepressive agents for major depressive disorder: a systematic review and meta-analysis

BACKGROUND

Escitalopram is selective serotonin reuptake inhibitors (SSRIs) and one of the most commonly prescribed newer antidepressants (ADs) worldwide. We aimed to explore the efficacy, acceptability and tolerability of escitalopram in comparison with other ADs in the acute-phase treatment of major depressive disorder (MDD).

METHODS

Medline/PubMed, EMBASE, the Cochrane Library, CINAHL, and Clinical Trials.gov were searched from inception to July 10, 2023. Trial databases of drug-approving agencies were hand-searched for published, unpublished and ongoing controlled trials. All randomized controlled trials comparing escitalopram against any other antidepressant for patients with MDD. Responders and remitters to treatment were calculated on an intention-to-treat basis. For dichotomous data, risk ratios (RRs) were calculated with 95% confidence intervals (CI). Continuous data were analyzed using standardized mean differences (with 95% CI) using the random effects model.

RESULTS

A total of 30 studies were included in this meta‑analysis, among which sixteen trials compared escitalopram with another SSRI and 14 compared escitalopram with a newer AD. Escitalopram was shown to be significantly more effective than citalopram in achieving acute response (RR 0.67, 95% CI 0.50-0.87). Escitalopram was also more effective than citalopram in terms of remission (RR 0.53, 95% CI 0.30-0.93).

CONCLUSIONS

Escitalopram was superior to other ADs for the acute phase treatment of MDD in terms of efficacy, acceptability and tolerability. However, no significant difference was found between escitalopram and other ADs in early response or follow-up response to treatment of MDD.

Nonresponder does not mean not better: Improvement in nonsymptom domains in complex depressed patients who are not symptomatic responders to intensive treatment

In treatment studies of depression, response is typically defined as a 50% or greater reduction in symptom severity. However, multiple surveys of depressed patients have found that patients prioritize improved functioning and quality of life objectives over symptom improvement as the most important goal of treatment. The goal of the present study is to widen the lens of assessing outcome by examining response in nonsymptom domains in patients who are, by convention, considered nonresponders to treatment. Eight hundred and forty-four patients with major depressive disorder completed the Remission from Depression Questionnaire (RDQ), a self-report measure that assesses multiple constructs considered by patients to be relevant to assessing treatment outcome. At discharge, the patients made a global rating of the effectiveness of treatment. The 517 patients who were nonresponders on the depression symptom subscale of the RDQ are the focus of this report. The patients showed significant levels of improvement from admission to discharge in all nonsymptom domains, with medium to large effect sizes. Approximately one-third of the patients were responders on at least 1 of the nonsymptom domains. The failure to meet the conventional definition of treatment response based on symptom severity does not preclude significant improvement in nonsymptom domains.

Trends in sales of antidepressants in Brazil from 2014 to 2020: A time trend analysis with joinpoint regression

BACKGROUND

This study aimed to investigate the trends in antidepressants sales in Brazil.

METHODS

We performed a joinpoint analysis of antidepressants sales in Brazil from 2014 to 2020, recorded in the Brazilian National Controlled Products Management System. The primary outcomes were the defined daily dose per 1000 inhabitants per day (DID) and the market shares for each antidepressant per year. We used joinpoint regression to assess the changes in antidepressant consumption in DID to obtain the average annual percent change (AAPC) and 95 % confidence intervals (95 % CI). Changes in market shares were tested by chi-square trend test (p < 0.05 as significant).

RESULTS

From 2014 to 2020, 42,252,989 antidepressant sales were recorded in the system. Antidepressant sales increased from 13.7 to 33.6 DID in the period (AAPC: 15.7; 95 % CI: 13.0-18.4; p < 0.001); the largest increases were observed for serotonin reuptake inhibitors and 'other' antidepressants (including serotonin-norepinephrine reuptake inhibitors), whereas tricyclics remained steady. Escitalopram and sertraline were the most sold drugs. Market share of serotonin reuptake inhibitors decreased, particularly for paroxetine (13.1 % to 6.5 %; p = 0.016), while 'other' antidepressants' market share expanded from 21.9 % to 33.3 % (p = 0.027), especially for desvenlafaxine (2.9 % to 14.3 %; p < 0.001).

LIMITATIONS

The dataset does not include antidepressants dispensed in hospitals, public services, and compounding pharmacies, neither their therapeutic indications.

CONCLUSION

Sales of antidepressants significantly increased in Brazil from 2014 to 2020, which were mainly driven by higher prescriptions of serotonin reuptake inhibitors and 'other' antidepressants classes. Market share changes seem to be driven by novelty of products.

Effect of antidepressants on functioning and quality of life outcomes in children and adolescents with major depressive disorder: a systematic review and meta-analysis

Functioning and quality of life (QOL) are typical outcomes assessed in children and adolescents with major depressive disorder (MDD); however, meta-analytical evidence remains scarce. The aim of this meta-analysis was to assess functioning and QOL antidepressant outcomes in this population. Eight electronic databases (PubMed, Cochrane Library, Web of Science, Embase, CINAHL, PsycINFO, LILACS, and ProQuest Dissertation Abstracts) were searched for double-blind randomized controlled trials (RCTs) up to July 31, 2020. RCTs that compared antidepressants with placebo for treating functioning and QOL in children and adolescents with MDD were included. Primary outcomes were mean change scores of functioning and QOL scales from baseline to post-treatment. Subgroup and sensitivity analyses were conducted to examine whether results were affected by moderator variables (e.g., medication type, age, sample size, and treatment duration). From 7284 publications, we included 17 RCTs (all 17 assessed functioning and 4 assessed QOL outcomes) including 2537 participants. Antidepressants showed significant positive effects on functioning (standardized mean difference [SMD] = 0.17, 95% confidence interval [CI] = 0.09-0.25, p < 0.0001) but not on QOL (SMD = 0.11, 95% CI = -0.02 to 0.24, p = 0.093), with no significant heterogeneity. The subgroup analysis showed that second-generation antidepressants (especially fluoxetine, escitalopram, and nefazodone), but not first-generation antidepressants, led to significant improvements in functioning. Antidepressants (especially second generation) improve functioning but not QOL in children and adolescents with MDD. However, well-designed clinical studies using large samples are needed to confirm these findings.

Therapeutic drug monitoring of sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of obsessive-compulsive disorder

BACKGROUND

Sertraline is a selective serotonin reuptake inhibitor with specific indications in child and adolescent psychiatry. Notwithstanding its frequent use and clinical benefits, the relationship between pharmacokinetics, pharmacodynamics, efficacy, and tolerability of sertraline across indications, particularly in non-adult patients, is not fully understood.

METHOD

This naturalistic therapeutic drug monitoring (TDM) study was conducted in a transdiagnostic sample of children and adolescents treated with sertraline (n = 78; mean age, 14.22 ± 2.39; range, 7-18 years) within the prospective multicenter "TDM-VIGIL" project. Associations between dose, serum concentration, and medication-specific therapeutic and side effects based on the Clinical Global Impression scale were examined. Tolerability was measured qualitatively with the 56-item Pediatric Adverse Event Rating Scale.

RESULTS

A strong linear positive dose-serum concentration relationship (with dose explaining 45% of the variance in concentration) and significant effects of weight and co-medication were found. Neither dose nor serum concentration were associated with side effects. An overall mild-to-moderate tolerability profile of sertraline was observed. In contrast with the transdiagnostic analysis that did not indicate an effect of concentration, when split into depression (MDD) and obsessive-compulsive disorder (OCD) diagnoses, the probability of clinical improvement significantly increased as both dose and concentration increased for OCD, but not for MDD.

CONCLUSIONS

This TDM-flexible-dose study revealed a significant diagnosis-specific effect between sertraline serum concentration and clinical efficacy for pediatric OCD. While TDM already guides clinical decision-making regarding compliance, dose calibration, and drug-drug interactions, combining TDM with other methods, such as pharmacogenetics, may facilitate a personalized medicine approach in psychiatry.

Psychiatric medication and physical performance parameters - Are there implications for treatment?

INTRODUCTION

The impact of psychiatric medications and their enhancing or impairing effects on physical performance remains inconclusive. Therefore, with this systematic review we provide a comprehensive overview of frequently used psychotropic drugs and their effects on physical performance for the purpose of providing empirical information and deriving prescription and therapy recommendations for clinical practice.

METHODS

We systematically searched PubMed, PsycInfo, and Cochrane databases and extracted human studies investigating the effect of psychotropic drugs on parameters associated with the level of physical performance, such as exercise time, oxygen consumption, heart rate, muscle contraction or blood lactate concentration in physically healthy participants. 36 studies - comprising a broad range of psychotropic agents, such as antidepressants, antipsychotics, sedatives, and stimulants - were selected for final analyses.

RESULTS

Most studies (N = 32) were randomized controlled trials (RCT) with a double-blind crossover design. Antidepressants (N = 21) were the most frequently studied drug class, with contradictory results e.g., performance enhancement in warm environment but not in temperate conditions for bupropion or inconsistent findings between studies for other antidepressants. Antipsychotics (N = 3) mainly showed impairing effects on physical performance, while stimulants (N = 4) were often performance-enhancing. Sedatives (N = 9) may cause a hangover effect.

CONCLUSION

The examined studies with heterogeneous design showed different effects of psychiatric medications on physical performance. Antipsychotics seemed to be performance impairing, while the findings for antidepressants and sedatives were more inconsistent. Stimulants were the only group with consistent performance-enhancing effects. However, most studies were conducted with a small sample size (N < 10), mostly in well-trained subjects rather than in patients with psychiatric disorders, and most studies used single-dose designs. These issues impede the formulation of generalized conclusions for treatment regimes and should therefore be considered in further longitudinal studies for clinically reliable statements. Nevertheless, answering our research question is quite relevant for clinical practice and therapeutic prescription and should be further investigated especially considering the high drop-out rates in drug treatment.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=276103], identifier [CRD42021276103].

In search of sex-related mediators of affective illness

Sex differences in the rates of affective disorders have been recognized for decades. Studies of physiologic sex-related differences in animals and humans, however, have generally yielded little in terms of explaining these differences. Furthermore, the significance of these findings is difficult to interpret given the dynamic, integrative, and highly context-dependent nature of human physiology. In this article, we provide an overview of the current literature on sex differences as they relate to mood disorders, organizing existing findings into five levels at which sex differences conceivably influence physiology relevant to affective states. These levels include the following: brain structure, network connectivity, signal transduction, transcription/translation, and epigenesis. We then evaluate the importance and limitations of this body of work, as well as offer perspectives on the future of research into sex differences. In creating this overview, we attempt to bring perspective to a body of research that is complex, poorly synthesized, and far from complete, as well as provide a theoretical framework for thinking about the role that sex differences ultimately play in affective regulation. Despite the overall gaps regarding both the underlying pathogenesis of affective illness and the role of sex-related factors in the development of affective disorders, it is evident that sex should be considered as an important contributor to alterations in neural function giving rise to susceptibility to and expression of depression.

The joint effects of clinically relevant depressive symptoms and cardiovascular risk factors on incident cardiovascular disease among older adults in the community

OBJECTIVE

To determine if there is a synergistic effect between clinically relevant depressive symptoms and cardiovascular risk factors that disproportionately increases the risk of cardiovascular disease (CVD) among older adults with depressive symptoms.

METHODS

Data were obtained from the Longitudinal Aging Study Amsterdam, a longitudinal cohort study. N = 3091 respondents with up to seven years of follow-up were included. Incident CVD was based on self-report, medication use, general practitioners' diagnoses and causes of death. A score of ≥16 points on the Center for Epidemiological Studies Depression Scale indicated clinically relevant depressive symptoms. Risk factors included were sex, education, obesity, smoking, alcohol use, physical inactivity and diabetes mellitus. Data were analysed with Cox regression models. Measures of multiplicative and additive interaction were calculated to determine if the presence of both depressive symptoms and a risk factor amplified the risk of CVD.

RESULTS

Of all participants, 12.6% had clinically relevant depressive symptoms and, after a median follow-up of six years, 15.7% developed CVD. Only the additive interaction between physical inactivity and depressive symptoms was statistically significant and explained 40.6% of the CVD risk among inactive persons with depressive symptoms.

CONCLUSION

In the general population, we did not detect synergistic effects for most risk factors. However, older adults with clinically relevant depressive symptoms and a physically inactive lifestyle appeared to be at a particularly high risk to develop CVD and may represent an important target for cardiovascular prevention.

Intrahippocampal Effects of Nickel Injection on the Affective and Cognitive Response in Wistar Rat: Potential Role of Oxidative Stress

The present study focused on affective and cognitive behaviors in male Wistar rats, following direct and unique exposure to nickel chloride (NiCl₂), as well as the possible involvement of oxidative stress. The rats were exposed to NiCl₂ (300 μM), by intracerebral administration of 2 μL of this metal at the right hippocampus, using the stereotaxic approach. Five days after the surgery, a battery of behavioral tests was performed, including the open-field test (OFT) and elevated plus maze test (EPM) to assess the state of anxiety-like behavior and forced swimming test (FST) for depressive-like behavior. Y-maze and Morris Water Maze (MWM) were used to evaluate working memory and spatial learning. Thereafter, oxidative stress markers of the hippocampus were evaluated. The results confirm that NiCl₂ exerts anxiogenic effects in both anxiety tests and depressogenic effects in the FST. In addition, MWM and Y-maze data show that NiCl₂ causes memory and spatial learning disorders. The biochemical assay results showed that intrahippocampal injection of NiCl₂ increased the levels of nitric oxide and lipid peroxidation (p < 0.001), while the activities of catalase and superoxide dismutase were significantly decreased in the hippocampus (p < 0.01). Overall, these results suggest that NiCl₂ causes affective and cognitive disorders and oxidative stress in rats.

Impact of Antidepressant Prescriptions on Suicidal Behavior in Times of Severe Financial Strain

ABSTRACT

This descriptive study observes the relationship between antidepressant prescriptions and the suicide rate in Italy in the 2000s to the mid-2010s, which includes a period of severe economic crisis. The observation period was from 2000 to 2015. Suicide and unemployment rates disaggregated by age and sex were collected from the Italian Institute of Statistics. Statistical analyses were performed using correlations between suicide rates and the defined daily dose, with reference to selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and other types of antidepressants. Fixed-effects panel regressions were also run. Increases in SSRIs prescriptions were associated with decreases in suicide rates among both men and women. However, when the analyses were adjusted for the rate of growth of the unemployment rate and for gross domestic product, the associations were weaker. The potential protective factor of SSRIs with respect to suicidal behavior may be reduced by severe recessions, especially when unemployment increases.

Effect of neuropsychiatric medications on mitochondrial function: For better or for worse

Individuals with mitochondrial disease often present with psychopathological comorbidity, and mitochondrial dysfunction has been proposed as the underlying pathobiology in various psychiatric disorders. Several studies have suggested that medications used to treat neuropsychiatric disorders could directly influence mitochondrial function. This review provides a comprehensive overview of the effect of these medications on mitochondrial function. We collected preclinical information on six major groups of antidepressants and other neuropsychiatric medications and found that the majority of these medications either positively influenced mitochondrial function or showed mixed effects. Only amitriptyline, escitalopram, and haloperidol were identified as having exclusively adverse effects on mitochondrial function. In the absence of formal clinical trials, and until such trials are completed, the data from preclinical studies reported and discussed here could inform medication prescribing practices for individuals with psychopathology and impaired mitochondrial function in the underlying pathology.

Antidepressant responses in direct comparisons of melancholic and non-melancholic depression

BACKGROUND

Efforts to develop less heterogeneous, more clinically useful diagnostic categories for depressive disorders include renewed interest in the concept of melancholia (Mel). However, clinical or biological differentiation of Mel from other (nonMel) episodes of depression has been questioned, and it remains unclear whether pharmacological responses proposed to be characteristic of Mel are supported by available research.

METHODS

We carried out a systematic review seeking treatment trials reports comparing Mel and nonMel depressed subjects for meta-analyses of their differences in responses (a) to antidepressants overall, (b) to tricyclic (TCAs) or serotonin-enhancing agents (serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors) and (c) with placebo treatment.

RESULTS

We identified 25 trials in 16 reports comparing 2597 Mel with 5016 nonMel subjects. Overall, responses to antidepressant treatment did not differ between Mel (39.4%) and nonMel (42.2%) subjects. However, all subjects responded better to TCAs (50.6%) than SRIs (30.0%; p<0.0001). Mel subjects also responded less well with placebo, but also were significantly more severely depressed at intake.

CONCLUSIONS

Antidepressant responses were similar in Mel and nonMel depressed patients. Mel subjects responded 25% less with placebo but were more severely depressed initially, and there was preferential response to TCAs in both Mel and nonMel subjects. The findings provide little support for proposed differences in responses to particular treatments among Mel versus nonMel depressed patients, and underscore the need to match for illness severity in making such comparisons.

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.

Efficacy evaluation of exercise as an augmentation strategy to brief behavioral activation treatment for depression: a randomized pilot trial

Exercise is an efficacious intervention for mental and physical health, but few studies have identified the additive benefits of exercise prescriptions for those undergoing empirically supported psychosocial treatment. Behavioral activation (BA) involves completing activities to improve mood, an ideal format for exercise augmentation. The purpose of this study was to examine the credibility and exploratory effect size estimates of augmenting BA with exercise. Thirty-one sedentary, depressed patients were randomized to receive nine sessions of BA+exercise or BA+stretching over 12 weeks. Monthly assessments of depression, quality of life, distress intolerance (DI), perceived stress, and exercise were conducted. Results demonstrated strong credibility and completion rates of BA+exercise, comparable to other PA interventions. Randomization did not contribute to differential exercise between conditions; all participants engaged in more exercise over time. Similarly, all participants significantly improved on all outcomes over time. Condition differences emerged for DI and perceived stress; the exercise condition evidenced greater improvements over time. Participants who engaged in more exercise also evidenced greater and faster declines in depression. BA may be a useful strategy for improving depression and increasing exercise. Additional explicit exercise prescriptions may not be necessary to improve depression but may be helpful for DI and stress. Clinical Trials Registry (clinicaltrials.gov): NCT02176408, "Efficacy of Adjunctive Exercise for the Behavioral Treatment of Major Depression".

How to choose an antidepressant medication

OBJECTIVE

We consider how to choose an antidepressant (AD) medication for the treatment of clinical depression.

METHOD

A narrative review was undertaken addressing antidepressant 'choice' considering a range of parameters either weighted by patients and clinicians or suggested in the scientific literature. Findings were synthesised and incorporated with clinical experience into a model to assist AD choice.

RESULTS

Efficacy studies comparing ADs offer indicative guidance, while precision psychiatry prediction based on genetics, developmental trauma, neuroimaging, behavioural and cognitive biomarkers, currently has limited clinical utility. Our model offers guidance for AD choice by assessing first for the presence of a depressive subtype or symptom cluster and matching choice of AD class accordingly. Failing this, an AD can be chosen based on depression severity. Within-class choice can be determined by reference to personality style, patient preference, medical or psychiatric comorbidities and side-effect profile.

CONCLUSION

Clarification of AD choice would occur if medications are trialled in specific depressive subtypes rather than using the generic diagnosis of major depressive disorder (MDD). Such 'top-down' methods could be enhanced by 'bottom-up' studies to classify individuals according to symptom clusters and biomarkers with AD efficacy tested in these categories. Both methods could be utilised for personalised AD choice.

Depression

Major depression is a common illness that severely limits psychosocial functioning and diminishes quality of life. In 2008, WHO ranked major depression as the third cause of burden of disease worldwide and projected that the disease will rank first by 2030.¹ In practice, its detection, diagnosis, and management often pose challenges for clinicians because of its various presentations, unpredictable course and prognosis, and variable response to treatment.