09 March 2012

Overall benefit from antidepressants

Despite debate about how well antidepressants really work in people with only mild or moderate depression, a new meta-analysis suggests they may have some benefit across the board.


Despite recent debate about how well antidepressants really work in people with only mild or moderate depression, a new meta-analysis suggests they may have some benefit across the board.

Researchers found that more patients taking Prozac (fluoxetine) or Effexor (venlafaxine) had a substantial improvement in their symptoms than those given placebo, regardless of baseline symptom severity.

"The idea that unless you're very, very ill, you're not going to benefit from treatment does not appear to stand up" when looking closely, said the study's lead author, Dr Robert Gibbons, from the University of Chicago.

Still, not everyone in the studies improved - the number needed to treat was slightly above five, and the benefits seemed diminished among some of the oldest patients.

Improvement in taking Prozac

For their analysis, Dr Gibbons and his colleagues looked at outcomes for each individual patient in published and unpublished trials testing the effects of six weeks of treatment with antidepressants versus placebo pills. Most of those trials were funded and run by the pharmaceutical companies that manufacture Prozac and Effexor – Eli Lilly and Wyeth, respectively.

They included 12 studies of Prozac in adults and four each in elderly patients and youths, as well as 21 trials of immediate- or extended-release Effexor in adults. About 9,000 participants were included.

More adults and kids taking Prozac had at least a 50% improvement in scores on depression tests after six weeks compared to those assigned to placebo.

55% of adults on Prozac responded to treatment, compared to 34% in the placebo group. In youth, 30% on Prozac had significant symptom improvement, compared to just 6% of controls.

What’s going on with the elderly?

The benefits were seen regardless of how severe patients' symptoms were before starting treatment.

However, in the elderly the differences between the treatment and placebo groups were much smaller, and the researchers calculated that 17 older patients would have to be treated with Prozac for one to gain from it.

"Clearly the efficacy of antidepressants is age-dependent, (and) largest, most interestingly, in youth, which I don't think would be the mainstream view in psychiatry," Dr Gibbons said.

The findings, he added, "raise other questions that need to be followed up including, what's going on in the elderly."

Doubts about other types of antidepressants

Both types of Effexor also seemed to help adults with mild to severe depression, with slightly more patients responding to the immediate-release dose.

Some of the study's authors have testified for or received funding from drug companies, though the report itself was funded by national health agencies.

The researchers said they couldn't be sure there would be similar improvements with other types of antidepressants – especially given the more limited data in kids and the elderly – or that the longer-term benefits would be as clear.

One recent study suggested that up to a fifth of patients on the antidepressant Cymbalta (duloxetine) might actually benefit more from placebo pills.

Dr Irving Kirsch, who studies antidepressants and placebos at Harvard Medical School in Boston, said the new report didn't make him more optimistic about the drugs.

Alternative treatments for depression

If five or more patients need to be treated with an antidepressant for one to substantially improve, most don't get much out of it, he pointed out.

"More than 80% of the patients are not getting a significant benefit from the drug – either they're not getting better or they would get the same benefit with placebo," he told Reuters Health.

"There are alternative treatments for depression that also produce about the same symptom reduction as the drugs do, but without the risk of side effects," Dr Kirsch added, including psychotherapy and exercise.

Still, Dr Gibbons said the improvement in symptoms for the average patient wasn't insignificant.

"Definitely it doesn't look like antidepressants are placebos," he concluded.

The report was released online in Archives of General Psychiatry.

(Genevra Pittman, Reuters Health, March 2012) 

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Depression expert

Michael Simpson has been a senior psychiatric academic, researcher, and Professor in several countries, having worked at London University in the UK; McMaster University in Canada; Temple University in Philadelphia, USA.; and the University of Natal in South Africa.

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