A systematic review 1 including 8 RCTs (n=approximately 4 000) and 23 non-randomised trials (13 controlled trials, n=1 219; 7 uncontrolled trials, n=1 086; 3 chart reviews, n=1 222) was abstracted in DARE.
• Second SSRI (3 RCTs and 7 non-randomised trials): 2 RCTs reported response and remission rates of 26.7 to 29% and 17.6%, respectively. However, the other studies (1 RCT and 7 non-randomised trials) reported response rates of around 50% in nonresponders and 70% in SSRI-intolerant patients.
• Tricyclic antidepressants and mianserin (2 RCTs and 4 non-randomised trials): the response rates varied from 16.5 to 48.5%, with lower response rates in studies with higher rates of treatment-resistant depression.
• Mirtazapine, nefazodone and venlafaxine (4 RCTs and 9 non-randomised trials): the pooling of 3 RCTs showed a small but statistically significant increase in remission and response rates associated with switching to venlafaxine versus SSRI (respectively: risk difference (RD) 8%, 95% CI 4 to 11; NNT 13, 95% CI 9 to 25; and RD 6%, 95% CI 1 to 10; NNT 17, 95% CI 10 to 100). Across all studies, the response rates were 28 to 50% in patients without overt treatment-resistant depression, and lower in studies with higher rates of treatment-resistant depression.
• Bupropion and reboxetine (1 RCT and 2 non-randomised trials): the response rates were 26 to 35% for bupropion and 45% for reboxetine.
• MAOI inhibitors: no studies using reversible MAOI inhibitors were found. Three RCTs reported efficacy rates for tranylcypromine, two with response rates of 43 to 46%. The third reported remission and response rates of 7% and 12%, respectively.
Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions).
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