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Evidence summaries

Second-Generation Antipsychotics for Major Depression and Dysthymia

In major depression quetiapine appears to be more effective than placebo. Aripiprazole, quetiapine and partly also olanzapine and risperidone augmentation, when added on antidepressants, also appears to be beneficial. In dysthymia, amisulpride appears to be beneficial. Most SGAs appears to have worse tolerability. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 28 RCTs with 8487 participants with major depression or dysthymia. Twenty-two studies were short-term, up to 12 weeks. Most of the studies included outpatient participants, in all trials the patients were diagnosed with dysthymia or major depression according to DSM-IV or DSM-III.

•Aripiprazole augmentation, when added to antidepressants in major depression: All efficacy data (response OR 0.48; 95% CI 0.37 to 0.63; 3 RCTs, n = 1092), (MADRS MD -3.04; 95% CI -4.09 to -2; 3 RCTs, n = 1077) indicated a benefit for aripiprazole but also more side effects, such as weight gain and extrapyramidal symptoms.

•Olanzapine augmentation and vs. placebo for psychotic depression: When compared to placebo, fewer people discontinued treatment due to inefficacy (OR 0.39; 95% CI 0.18 to 0.86; 2 RCTs, n = 201). When compared to antidepressants olanzapine augmentation showed symptom reduction (MADRS MD -2.84; 95% CI -5.48 to -0.20; 5 RCTs, n = 808), but also more weight or prolactin increase.

•Quetiapine vs. placebo and augmentation for major depression: Quetiapine monotherapy (response OR 0.52; 95% CI 0.41 to 0.66; 3 RCTs, n = 1342) and quetiapine augmentation, when added to antidepressants (response OR 0.68; 95% CI 0.52 to 0.90; 3 RCTs, n = 937) showed symptom reduction, but quetiapine induced more sedation.

•Risperidone augmentation for major depression: Response data was better for risperidone (OR 0.57; 95% CI 0.36 to 0.89; 2 RCTs, n = 371) but augmentation showed more prolactin increase and weight gain.

•Amisulpride vs. placebo for dysthymia: There was a significant difference in response in favour of amisulpride (OR 0.29; 95% CI 0.18 to 0.46; 2 RCTs, n = 322) but patients are more likely to suffer from menstrual disorder and weight gain.

Comment: The quality of the evidence is downgraded by study quality (unclear allocation concealment, short follow-up).

    References

    • Komossa K, Depping AM, Gaudchau A, Kissling W, Leucht S. Second-generation antipsychotics for major depressive disorder and dysthymia. Cochrane Database Syst Rev 2010 Dec 8;(12):CD008121. [PubMed]

Primary/Secondary Keywords