Selective serotonin reuptake inhibitor use in primary care: a 5-year naturalistic study

Low SSRI dosing in clinical practice-a register-based longitudinal study

OBJECTIVE

Since several recent meta-analyses report a dose-response relationship for the antidepressant effect of the selective serotonin reuptake inhibitors (SSRIs), we investigated how these drugs are dosed in clinical practice.

METHODS

Through linkage of nation- or region-wide registers, we describe SSRI doses in 50,365 individuals residing in Region Västra Götaland, Sweden, with an incident diagnosis of depression and initiating SSRI treatment between 2007 and 2016. The primary question was to elucidate to what extent these individuals had been prescribed a daily dose that according to recent meta-analyses is required to elicit the maximum antidepressant effect, that is >20 mg citalopram, >10 mg escitalopram, >10 mg fluoxetine, >10 mg paroxetine or >50 mg sertraline.

RESULTS

In all, 21,049 (54%) out of 38,868 individuals <65 years of age, and 9,131 (79%) out of 11,497 individuals ≥65 years of age, never received an SSRI dose reported to exert maximum antidepressant effect. These prescribing practices were seen for citalopram, escitalopram and sertraline, but not for fluoxetine and paroxetine, and were frequent in both primary and secondary/tertiary care. Suggesting that doses here defined as maximum efficacy doses, when prescribed, are usually not intolerable, between 59% and 68% of individuals <65 years of age received such a dose also for the subsequent prescription, that is as frequently as in those prescribed a sub-maximum efficacy dose (52-69%).

CONCLUSION

Most patients being prescribed an SSRI to treat their depression never receive the dose that according to recent meta-analyses is most likely to effectively combat their condition. The lack of consensus regarding effective dosing of SSRIs may have contributed to this state of affairs.

Raising the Minimum Effective Dose of Serotonin Reuptake Inhibitor Antidepressants: Adverse Drug Events

This review focuses on the dose-response of serotonin reuptake inhibitor (SRI) antidepressants for efficacy and for adverse drug events (ADEs). Dose-response is identified by placebo-controlled, double-blind, fixed-dose clinical trials comparing various doses for efficacy and for ADEs. Reports from the great majority of clinical trials have consistently found that the minimum SRI effective dose is usually optimal for efficacy in the treatment of depression disorders, even though most American medical practitioners raise the dose when early antidepressant treatment results are negative or partial. To better understand this issue, the medical literature was comprehensively reviewed to ascertain the degree to which SRI medications resulted in a flat dose response for efficacy and then to identify specific ADEs that are dose-dependent. Strong evidence from fixed-dose trial data for the efficacy of nonascendant, minimum effective doses of SRIs was found for the treatment of both major depression and anxiety disorders. Particularly important was the finding that most SRI ADEs have an ascending dose-response curve. These ADEs include sexual dysfunction, hypertension, cardiac conduction risks, hyperglycemia, decreased bone density, sweating, withdrawal symptoms, and agitation. Thus, routinely raising the SRI dose above the minimum effective dose for efficacy can be counter-productive.

Rapid-acting glutamatergic antidepressants: the path to ketamine and beyond

Traditional antidepressants require many weeks to reveal their therapeutic effects. However, the widely replicated observation that a single subanesthetic dose of the N-methyl-D-aspartate glutamate receptor antagonist ketamine produced meaningful clinical improvement within hours, suggested that rapid-acting antidepressants might be possible. The ketamine studies stimulated a new generation of basic antidepressant research that identified new neural signaling mechanisms in antidepressant response and provided a conceptual framework linking a group of novel antidepressant mechanisms. This article presents the path that led to the testing of ketamine, considers its promise as an antidepressant, and reviews novel treatment mechanisms that are emerging from this line of research.

Antidepressant use in clinical practice: efficacy v. effectiveness

BACKGROUND

Although the efficacy of antidepressants has been demonstrated in randomised, controlled clinical trials, it is how an antidepressant is used in clinical practice that determines its clinical effectiveness, or real-world efficacy.

AIMS

To explore the frequency with which antidepressants are used at adequate dose and duration to obtain remission of symptoms and prevent relapse in clinical practice and discuss potential implications for clinical outcomes.

METHOD

Studies of antidepressant prescribing were reviewed and comparisons made between antidepressant classes and individual compounds within those classes.

RESULTS

Naturalistic studies show that patients who begin therapy on tricyclic antidepressants often receive sub-therapeutic doses for inadequate duration; conversely, patients who begin therapy on selective serotonin reuptake inhibitors more often receive an adequate dose of therapy for a longer duration. CONCLUSIONS; How antidepressants are used in clinical practice can determine the clinical outcomes that are achieved. Antidepressants that are more forgiving of sub-optimal prescribing and use patterns by providers and patients, respectively, may help to improve real-world efficacy.

Optimising antidepressant use in clinical practice: towards criteria for antidepressant selection

BACKGROUND

Current treatment for depression in primary care and other out-patient settings demonstrates a pattern that is incongruous with the magnitude of the burden of depression suggested by its associated disability.

AIMS

To review important considerations in current depression treatment with a focus on antidepressant use.

METHOD

Factors influencing the undertreatment of depression in real-world settings are examined.

RESULTS

Patient and clinician behaviour as well as the incentives created by the health care system affect the likelihood of realising effective antidepressant therapy in practice.

CONCLUSIONS

Given the complexities of clinical practice, selection criteria for an antidepressant should include safety, efficacy and tolerability, as well as the ability of the antidepressant to deliver real-world efficacy while balancing health care costs in the long term.

Antidepressant use patterns in clinical practices: comparisons among tricyclic antidepressants and selective serotonin reuptake inhibitors

OBJECTIVE

Antidepressant use in clinical practice may differ from that in randomized controlled trials due to the complex interaction between patients, prescribers and the health-care system.

METHOD

A review of studies using data from actual clinical practice has found consistent differences in the prescribing patterns of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs).

RESULTS

Patients who initiate therapy on SSRIs are more likely to complete a course of adequate dose and duration of antidepressant therapy than patients who initiate therapy on a TCA. Differences in prescribing patterns have also emerged among the most common SSRIs, fluoxetine, sertraline and paroxetine, that are also consistent over time, settings and countries.

CONCLUSION

Given that the drugs studied are one constant across all the studies, the antidepressants' underlying pharmacological differences in tolerability and other properties may provide an explanation for differences in prescribing patterns.