PsychoTropicalResearch, serotonin and serotonin syndrome research.
Antidepressants - Efficacy
Antidepressants - Efficacy
Date Created: 22/03/1999 Last Modified: 18/04/2001 Last Checked: 20/01/2003
As far as curing depression and preventing deaths from suicide are concerned under-treatment and therapeutic failure are important issues in antidepressant treatment, perhaps more so than toxicity in overdose.
There is evidence that a greater proportion of patients commit suicide on some antidepressants drugs compared to others. Since suicide is the ultimate objective outcome measure of the failure of antidepressant treatment this suggests the possibility these drugs are less effective in treating the illness.
A greater proportion of patients commit suicide on:--
moclobemide
citalopram, paroxetine, fluvoxamine
trimipramine, doxepin, dothiepin
trazodone, nefazodone and mianserin.
It is axiomatic that good evidence of long term efficacy is an absolute prerequisite for being confident a new drug is worth using; having less side effects, or being less toxic in overdose, is irrelevant if the drug is in reality less effective at treating the illness.
With depression it is the disease which kills people, not the treatment.
The plethora of new antidepressant drugs highlights the dilemma that exists in deciding whether to try one of them, instead of more tested remedies that may (not always) have slightly more side effects (viz the old TCAs).
Consider these points:--
*** depression kills a lot of people, as many as 15% of patients with major depression die by suicide.
*** only a small percentage of deaths by suicide (<10%) result from over-dose of prescribed antidepressant drugs. (search 'toxicity')
*** failure to recognise and treat at all, and failure of the treatment that is given, are the major causes of morbidity and mortality, not the toxicity of antidepressant drugs.
Few trials of new drugs convincingly establish their effectiveness (vs placebo or the TCAs) for sustaining remission in the long term or reducing death by suicide.
In all western democracies the regulatory agencies (FDA and CSM etc) are dependent on limited drug data from the manufacturer when making decisions about approval; it is inevitable that such data in some respects lacks balance. It is only when drugs are used in routine clinical practice, in larger numbers of patients for longer periods of time, that a more objective assessment by disinterested observers is possible.
Some meta-analyses suggest several newer drugs are in fact less effective than amitriptyline.
So remember, therapeutic failure is an important issue in antidepressant treatment. It is of limited use giving a new drug with less side effects if it is less effective.
All text ©Dr Ken Gillman MRC Psych - PsychoTropical Research®
|Return to the menu at the top of this page|