Fluoxetine versus other types of pharmacotherapy for depression.
ABSTRACT Depression is common in primary care and it is associated with marked personal, social and economic morbidity, and creates significant demands on service providers in terms of workload. Treatment is predominantly pharmaceutical or psychological. Fluoxetine, the first of a group of antidepressant (AD) agents known as selective serotonin reuptake inhibitors (SSRIs), has been studied in many randomised controlled trials (RCTs) in comparison with tricyclic (TCA), heterocyclic and related ADs, and other SSRIs. These comparative studies provided contrasting findings. In addition, systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to fluoxetine alone. The present systematic review assessed the efficacy and tolerability profile of fluoxetine in comparison with TCAs, SSRIs and newer agents.
To determine the efficacy of fluoxetine, compared with other ADs, in alleviating the acute symptoms of depression, and to review its acceptability.
Relevant studies were located by searching the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR), the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (1966-2004) and Embase (1974-2004). Non-English language articles were included.
Only RCTs were included. For trials which have a crossover design only results from the first randomisation period were considered.
Data were independently extracted by two reviewers using a standard form. Responders to treatment were calculated on an intention-to-treat basis: drop-outs were always included in this analysis. When data on drop-outs were carried forward and included in the efficacy evaluation, they were analysed according to the primary studies; when dropouts were excluded from any assessment in the primary studies, they were considered as treatment failures. Scores from continuous outcomes were analysed including patients with a final assessment or with the last observation carried forward. Tolerability data were analysed by calculating the proportion of patients who failed to complete the study and who experienced adverse reactions out of the total number of randomised patients. The primary analyses used a fixed effects approach, and presented Peto Odds Ratio (PetoOR) and Standardised Mean Difference (SMD).
On a dichotomous outcome fluoxetine was less effective than dothiepin (PetoOR: 2.09, 95% CI 1.08 to 4.05), sertraline (PetoOR: 1.40, 95% CI 1.11 to 1.76), mirtazapine (PetoOR: 1.64, 95% CI 1.01 to 2.65) and venlafaxine (Peto OR: 1.40, 95% CI 1.15 to 1.70). On a continuous outcome, fluoxetine was more effective than ABT-200 (Standardised Mean Difference (SMD) random effects: - 1.85, 95% CI - 2.25 to - 1.45) and milnacipran (SMD random effects: - 0.38, 95% CI - 0.71 to - 0.06); conversely, it was less effective than venlafaxine (SMD random effect: 0.11, 95% CI 0.00 to 0.23), however these figures were of borderline statistical significance. Fluoxetine was better tolerated than TCAs considered as a group (PetoOR: 0.78, 95% CI 0.68 to 0.89), and was better tolerated in comparison with individual ADs, in particular than amitriptyline (PetoOR: 0.64, 95% CI 0.47 to 0.85) and imipramine (PetoOR: 0.79, 95% CI 0.63 to 0.99), and among newer ADs than ABT-200 (PetoOR: 0.21, 95% CI 0.10 to 0.41), pramipexole (PetoOR: 0.20, 95% CI 0.08 to 0.47) and reboxetine (PetoOR: 0.61, 95% CI 0.40 to 0.94).
There are statistically significant differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain, and no definitive implications for clinical practice can be drawn. From a clinical point of view the analysis of antidepressants' safety profile (adverse effect and suicide risk) remains of crucial importance and more reliable data about these outcomes are needed. Waiting for more robust evidence, treatment decisions should be based on considerations of clinical history, drug toxicity, patient acceptability, and cost. We need for large, pragmatic trials, enrolling heterogeneous populations of patients with depression to generate clinically relevant information on the benefits and harms of competitive pharmacological options. A meta-analysis of individual patient data from the randomised trials is clearly necessary.
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ABSTRACT: This is the protocol for a review and there is no abstract. The objectives are as follows: To examine the effectiveness and acceptability of all integrative therapies compared with all other psychological therapy approaches for acute depression.To examine the effectiveness and acceptability of different integrative therapy models (IPT, CAT, psychodynamic-interpersonal therapy, CBASP, counselling) compared with all other psychological therapy approaches for acute depression.To examine the effectiveness and acceptability of all integrative therapies compared with different psychological therapy approaches (psychodynamic, behavioural, humanistic, cognitive-behavioural, third wave CBT) for acute depression.Cochrane database of systematic reviews (Online) 01/2010; · 5.70 Impact Factor
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ABSTRACT: Objetivo: Avaliar a eficácia dos inibidores da recaptação da serotonina e noradrenalina (SNRI) face aos inibidores seletivos da recap-tação da serotonina (SSRI) na indução de remissão na perturbação depressiva major. Fontes de dados: PubMed, bases de dados de medicina baseada na evidência e o Índex de Revistas Médicas Portuguesas. Métodos da revisão: Pesquisa de normas de orientação clínica (NOC), revisões sistemáticas e meta-análises publicadas até 13/01/2013, bem como de ensaios clínicos (ECA) desde 01/01/2011 até 13/01/2013, utilizando os termos MeSH depressive disorder, major; venla-faxine; duloxetine, bem como os descritores portugueses depressão e antidepressivos de segunda geração. Para classificar a força de re-comendação e os níveis de evidência foi utilizada a escala Strength of Recommendation Taxonomy (SORT), da American Family Physician. Resultados: Foram encontrados 223 artigos. Destes, três NOC e nove revisões sistemáticas/meta-análises foram selecionadas. Ne-nhum ECA cumpria os critérios de inclusão. Tanto os SNRI como os SSRI são considerados terapêutica de primeira linha (nível de evi-dência [LE] 1) e não há evidência clara de superioridade dos SNRI face aos SSRI (LE 2). Contudo, a evidência mais consistente indica a maior eficácia da venlafaxina sobre a fluoxetina e paroxetina (LE 2). As NOC salientam a importância de escolher um antidepressivo com base no seu perfil de segurança e em aspetos relacionados com o paciente (LE 1). Conclusões: Tanto os SNRI como os SSRI são uma boa escolha (força de recomendação [SOR] A) para o tratamento da depressão. As características do fármaco e do paciente têm de ser levadas em conta na escolha do antidepressivo (SOR A). Num doente sem mor-bilidades, alguns SNRI mostram maior eficácia na remissão da depressão, mas não se pode falar de um efeito de classe. A escolha de SNRI em detrimento de um SSRI para atingir a remissão da depressão não é suportada pela evidência atual (SOR B).Revista Portuguesa de Medicina Geral e Familiar. 06/2014; 30(3):174-80.
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ABSTRACT: This is the protocol for a review and there is no abstract. The objectives are as follows: To examine the effectiveness and acceptability of all BT approaches compared with treatment as usual/waiting list/attention placebo control conditions for acute depression.To examine the effectiveness and acceptability of different BT approaches (behavioural therapy, behavioural activation, social skills training and relaxation training) compared with treatment as usual/waiting list/attention placebo control conditions for acute depression.To examine the effectiveness and acceptability of all BT approaches compared with different types of comparator (standard care, no treatment, waiting list, attention placebo) for acute depression.Cochrane database of systematic reviews (Online) 01/2010; · 5.70 Impact Factor