Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis

MacGillivray, Stephen; Arroll, Bruce; Hatcher, Simon; Ogston, Simon; Reid, Ian; Sullivan, Frank; Williams, B.; Crombie, Iain K.

doi:10.1136/bmj.326.7397.1014

Cited by 225 publications

(132 citation statements)

References 12 publications

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“…23 We found only 15 studies based in primary care that met inclusion criteria and provided evidence for the comparative effi cacy of TCAs and SSRIs vs placebo. We similarly found relatively few studies in a previous review of trials comparing SSRIs with TCAs in primary care, 13 as opposed to the considerably larger number of studies conducted with patients from all settings. Williams et al 31 found 206 studies comparing a newer with an older antidepressant (123 of which involved an SSRI).…”

Section: Discussionmentioning

confidence: 82%

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Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared With Placebo for Treatment of Depression in Primary Care: A Meta-Analysis

Arroll

MacGillivray²,

Ogston³

et al. 2005

The Annals of Family Medicine

298

164

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PURPOSE Depression is common in primary care. There are no systematic reviews of depression treatment comparing antidepressants with placebo; hence, we do not know whether these medications are effective in primary care. METHODSWe searched the Cochrane Collaboration Depression, Anxiety and Neurosis Group register of controlled trials, MEDLINE, International Pharmaceutical abstracts, PsycINFO, and EMBASE. Abstracts of potential studies were reviewed independently by 2 authors. Studies needed to include randomized controlled trials of either a tricyclic antidepressant (TCA) or selective serotonin reuptake inhibitor (SSRI), or both, and placebo in a primary care setting. The data and quality of the studies were extracted and assessed by 2 authors blind to the other's choice. Disagreements were resolved by discussion. The main outcome measures were the standardized mean difference and weighted mean difference of the fi nal mean depression scores, the relative risk of improvement, and the number withdrawing because of side effects. Pooling of results was done using Review Manager 4.2.2.RESULTS There were 10 studies in which TCAs were compared with placebo, 3 in which SSRIs were compared with placebo, and 2 with both compared with placebo. One half of the studies were of low methodological quality, and nearly all studies were of short duration, typically 6 to 8 weeks. Pooled estimates of effi cacy data showed a relative risk of 1.26 (95% CI, 1.12-1.42) for improvement with TCAs compared with placebo; For SSRIs, relative risk was 1.37 (95% CI, 1.21-1.55). Most patients, 56% to 60%, responded well to active treatment compared with 42% to 47% for placebo. The number needed to treat for TCAs was about 4, and for SSRIs it was 6. The numbers needed to harm (for withdrawal caused by side effects) ranged from 5 to 11 for TCAs and 21 to 94 for SSRIs. Low-dose (100 mg or 75 mg) as well as high-dose TCAs were effective.CONCLUSION This systematic review is the fi rst comparing antidepressants with placebo for treatment of depression in primary care. Both TCAs and SSRIs are effective. This review is also the fi rst to show that low-dose TCAs are effective in primary care. Prescribing antidepressants in primary care is a more effective clinical activity than prescribing placebo. Doubts about the effectiveness of antidepressant medication and other therapies, such as cognitive therapy, may contribute to the variability in primary care management of depression.3,4 Up to 40% of depressed patients fail to show a response to fi rst-line antidepressant drug treatment, 5 and of those that do respond, only a proportion will achieve full recovery.6 One cohort study of primary care patients found that 60% of depressed patients treated with medication and 50% with milder depression still met the criteria for caseness at 1 year. 7Recent reports have indicated an urgent need to review the evidence of only those studies of antidepressant effi cacy on patient samples based in primary care. 8,9 Several completed reviews and protocols are c...

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Section: Discussionmentioning

confidence: 82%

“…The Mulrow et al review 12 had a small section on antidepressant drugs vs placebo but reviewed only 4 studies. The MacGillivray et al review 13 compared selective serotonin reuptake inhibitors (SSRIs) with tricyclic antidepressants (TCAs) and therefore comment only on relative effi cacy. Comparison with placebo is needed to obtain absolute effi cacy.…”

mentioning

confidence: 99%

Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared With Placebo for Treatment of Depression in Primary Care: A Meta-Analysis

Arroll

MacGillivray²,

Ogston³

et al. 2005

The Annals of Family Medicine

298

164

View full text Add to dashboard Cite

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“…However, the evidence was sparse and of variable quality. 52 Whatever the true difference between classes, adherence is only an intermediate variable between efficacy and effectiveness, rather than an end in itself. Previous studies which have used adherence as part of cost-effectiveness models have assumed that effectiveness is equal between classes because for the most part, efficacy appears equal.…”

Section: Patient Non-adherencementioning

confidence: 99%

A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine

Peveler

Kendrick²,

Buxton³

et al. 2005

Health Technol Assess

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“…Trials comparing antidepressants head-to-head, eg SSRIs with TCAs, tend to find approximately equal efficacy, particularly when data are collated in meta-analyses. [10][11][12] Newer antidepressants including SSRIs and related types (selective noradrenaline reuptake inhibitorsSNRIs -and noradrenaline reuptake inhibitorsNARIs) are better tolerated and safer than either tricyclics or MAOIs, which can lead to cardiotoxicity or CNS depression in overdosage. There is still a role for MAOIs in cases of treatment-resistant depression, defined as depression unresponsive to two or more antidepressants given at an adequate dose for an adequate time.…”

Section: Efficacymentioning

confidence: 99%

Current approaches to the drug treatment of depression

Galloway¹,

MacGillivray²,

Reid³

2006

Prescriber

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Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis

Cited by 225 publications

References 12 publications

Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared With Placebo for Treatment of Depression in Primary Care: A Meta-Analysis

Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared With Placebo for Treatment of Depression in Primary Care: A Meta-Analysis

A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine

Current approaches to the drug treatment of depression

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