Antidepressants for Depression in Primary Care
Tricyclic antidepressants (TCAs) and selective serotonin re-uptake inhibitors (SSRIs) are effective in the treatment of depression in primary care, but there are more adverse effects with TCAs than with SSRIs. Level of evidence: "A"A Cochrane review [Abstract] 1 included 14 RCTs with a total of 2 283 subjects with depression. Ten studies examined tricyclic antidepressives (TCA) (imipramine, amitriptyline, dothiepin and mianserine), 2 examined selective serotonine reuptake inhibitors (SSRI) (citalopram, escitalopram) and 2 included both; all trials were placebo-controlled. The number of participants in the intervention groups was 1 364 and in the placebo groups 919. The Hamilton rating scale for depression (HAMD) or the Montgomery Asberg depression rating scale (MADRS) were the scales most commonly used. Nearly all studies were of short duration, typically 6-8 weeks.
- TCAs: For clinical response relative risk (RR) for benefit was 1.24 (95% CI 1.11 to 1.38) in favour of TCAs. The NNT for TCAs ranged from 7 to 16 (median NNT 9). For reduction in depression symptoms at post-treatment the standardised mean difference (SMD) was -0.49 (95% CI -0.67 to -0.32; 12 trials).
- SSRIs: For clinical response at post-treatment RR for benefit was 1.28 ( 95% CI 1.15 to 1.43; 4 trials). The NNT was from 7 to 8 (median NNT 7).
- The numbers needed to harm (NNH for withdrawal due to side effects) ranged from 4 to 30 for TCAs (excluding 3 studies with no harmful events leading to withdrawal) and 20 to 90 for SSRIs.
References
- Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G, Kerse N, Macgillivray S. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009 Jul 8;(3):CD007954. [PubMed]