A critical review of pharmacotherapy for major depressive disorder

Abstract

Newer generation antidepressant drugs, with improvements in safety and tolerability, have replaced tricyclic antidepressants as first-line treatment of depressive illness. However, no single antidepressant drug from any class has distinguished itself as the obvious first-line treatment of major depression. The choice of therapy is driven primarily by patient choice, with informed consent for the risks of adverse effects. Cost has become an additional factor in this decision as several of the newer antidepressant drugs are now available in generic form. Several augmentation and drug-switching strategies have demonstrated benefit in refractory illness. While no single strategy distinguished itself as superior to the others, some have been more rigorously tested. Ongoing efforts at improving effectiveness, time to response, and tolerability have led to novel drug therapies. Efforts at characterizing predictors of treatment outcomes now include pharmacogenetic studies.

Antipsychotic augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: a meta-analysis of double-blind, randomized, placebo-controlled trials

“…Compared to depression and anxiety disorders (Baldwin et al 2011 ;Batelaan et al 2012 ;Dupuy et al 2011), the treatment of OCD is associated with lower response rates and, as a rule, higher doses of antidepressants are used over a longer period of time (Bandelow, 2008). The APA guidelines advocate a period of at least 8-12 wk for the initial SRI medication (with at least 4-6 wk at the maximum tolerable dose), before a change of medication should be considered (APA, 2007).…”

Antidepressants: Relationship to the Time to Psychiatric Readmission and Probability of Being in Hospital in Depressive Patients

“…First generation antidepressants [tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)] were the mainstays for pharmacological treatment of depressive disorders for many years (6, 7). In the past decades, several new drugs (second-generation antidepressants) with improvements in safety and tolerability have been introduced (7–9). They include selective serotonin reuptake inhibitors (SSRIs; e.g., escitalopram, sertraline) and serotonin–norepinephrine reuptake inhibitors (SNRIs; e.g., venlafaxine, duloxetine).…”

“…They include selective serotonin reuptake inhibitors (SSRIs; e.g., escitalopram, sertraline) and serotonin–norepinephrine reuptake inhibitors (SNRIs; e.g., venlafaxine, duloxetine). In the US and Europe, SSRIs are most frequently prescribed (1, 9, 10). However, there are less prescriptions of SSRIs in Germany compared to other European countries (10).…”

“…However, despite the general efficacy of antidepressants, up to now it is not clear which single antidepressant drug is the obvious first-line treatment of depression (9). Recent reviews have stated that sertraline might be superior to its competitors with respect to efficacy, acceptability, and tolerability (6, 14, 15) as well as acquisition cost (15).…”

Keeping ’Em Honest

“…9,10 However, if clinical efficacy differences are negligible at the level of the individual patient, the choice of an antidepressant for that patient should be guided by other factors such as side effect profile and cost. 11 In 2009, Thase admitted, "Efficacy across all [antidepressant] drug classes is similar but underwhelming. " 12 This frank assessment of the evidence concurs with the most recent critical review of antidepressants, whose senior author was Andrew Nierenberg.…”