Antidepressants for depression in physically ill people

Rayner L, Price A, Evans A, Valsraj K, Higginson IJ, Hotopf M

Published Online:

April 14, 2010

Depression in physical illness is common. Antidepressants have been shown to improve depression in people who are physically healthy, but there has been doubt about whether they are appropriate for people who are physically ill. This review examined clinical trials of antidepressants in physically ill people to determine whether antidepressants help these patients, and in particular if they lessen depression. We used standard methods recommended by Cochrane to identify and select studies and to collect and analyse the information. We extracted information on fifty-one studies in the review. Our results found that antidepressants are better than a placebo (inactive) drug in treating depression in physically ill people. Both the two main classes of antidepressant, tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), were shown to be more effective than a placebo. Antidepressants improved depressive symptoms within 4-5 weeks of treatment, and this benefit persisted after 18 weeks. However, patients taking an antidepressant were more likely to experience sexual dysfunction and dry mouth, and were more likely to stop taking their medication after 6-8 weeks of treatment. There are no grounds to recommend one antidepressant over another on the basis of this review. We conclude that antidepressants appear to be useful in treating depression and should be considered for physically ill patients. The decision to prescribe antidepressants should take account of patients' preferences, symptoms, and possible interactions with other medicines they are taking.

Abstract (click to read)

Background:

There is an increased risk of depression in people with a physical illness. Depression is associated with reduced treatment adherence, poor prognosis, increased disability and higher mortality in many physical illnesses. Antidepressants are effective in the treatment of depression in physically healthy populations, but there is less clarity regarding their use in physically ill patients. This review updates Gill’s Cochrane review (2000), which found that antidepressants were effective for depression in physical illness. Since Gill there have been a number of larger trials assessing the efficacy of antidepressants in this context.

Objectives:

To determine the efficacy of antidepressants in the treatment of depression in patients with a physical illness.

Search strategy:

Electronic searches of the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) trial registers were conducted together with supplementary searches of The Cochrane Central Register of Controlled Trials (CENTRAL) and the standard bibliographic databases, MEDLINE, EMBASE and PsycINFO. Reference lists of included studies were scanned and trials registers were searched to identify additional unpublished data. Last searches were run in December 2009.

Selection criteria:

Randomised controlled trials comparing the efficacy of antidepressants and placebo in the treatment of depression in adults with a physical illness. Depression included diagnoses of Major Depression, Adjustment Disorder and Dysthymia based on standardised criteria.

Data collection and analysis:

The primary outcome was efficacy 6-8 weeks after randomisation. Data were also extracted at three additional time-points (4-5 weeks, 9-18 weeks, >18 weeks). Acceptability and tolerability were assessed by comparing the number of drop-outs and adverse events. Odds ratios with 95% confidence intervals were calculated for dichotomous data (response to treatment). Standardised mean differences with 95% CI were calculated for continuous data (mean depression score). Data were pooled using a random effects model.

Main results:

Fifty-one studies including 3603 participants were included in the review. Forty-four studies including 3372 participants contributed data towards the efficacy analyses. Pooled efficacy data for the primary outcome provided an OR of 2.33, CI 1.80-3.00, p<0.00001 (25 studies, 1674 patients) favouring antidepressants. Antidepressants were also more efficacious than placebo at the other time-points. At 6-8 weeks, fewer patients receiving placebo dropped out compared to patients treated with an antidepressant. Dry mouth and sexual dysfunction were more common in patients treated with an antidepressant.

Authors' conclusions:

This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.

This record should be cited as:

Rayner L, Price A, Evans A, Valsraj K, Higginson IJ, Hotopf M. Antidepressants for depression in physically ill people. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD007503. DOI: 10.1002/14651858.CD007503.pub2

Assessed as up to date:

December 10, 2009

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are antidepressants for depression in patients with a physical illness?

Bottom line:

Antidepressants were more effective than placebo in treating depression in physically ill patients. The superiority of antidepressants over placebo was apparent within 4–5 weeks (NNT* 6) and persisted after 18 weeks (NNT 7). Subgroup analysis showed both tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) were superior to placebo in treating depression in physically ill patients. Antidepressants were associated with increased rates of dry mouth (particularly TCAs) and sexual dysfunction (particularly SSRIs) compared with placebo. There was no evidence of a difference in drop-out between TCAs and SSRIs. Subgroup analysis suggested TCAs, which are often considered inappropriate for physically ill patients,1 are as effective and as acceptable to patients as SSRIs. There are no grounds to recommend a specific antidepressant on the basis of this review, which included studies evaluating a total of 22 different drugs. * NNT = number needed to treat to benefit 1 individual

Caveat:

At 6–8 weeks, there were more drop-outs among patients treated with an antidepressant than among patients treated with placebo (NNH**19), but no difference was observed at the other timepoints assessed. Due to potential biases, such as selective publication, small sample sizes and the variable methodological quality of trials, it is likely the effect sizes obtained in this review overestimate the efficacy of antidepressants. ** NNH = number needed to treat to cause harm in 1 individual

Context:

Antidepressants are effective in the treatment of depression in physically healthy populations, but there is less clarity regarding their use in physically ill patients.

Cochrane Systematic Review:

Rayner L et al. Antidepressants for depression in physically ill people. Cochrane Reviews 2010, Issue 3. Article No. CD0057503. DOI: 10.1002/14651858.CD007503.pub2. This review contains 51 studies involving 3603 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Mental health > Depression > Depressive disorders & major depression

Cochrane Summaries

Independent high-quality evidence for health care decision making

Antidepressants for depression in physically ill people

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