Second-Generation Antidepressants for Treating Adult Depression—An Update
Effectiveness in Treating Symptoms That May Accompany Depression
Anxiety: Key Points
Eleven head-to-head trials and two placebo-controlled trials examined treatment of accompanying anxiety symptoms in patients with major depressive disorder. Of the 14 trials, 6 compared various selective serotonin reuptake inhibitors (SSRIs) with each other, 6 compared an SSRI with a serotonin norepinephrine reuptake inhibitor (SNRI) or another second-generation drug, and 2 compared an SSRI or another second-generation drug with placebo. The strength of evidence that antidepressants are equally efficacious in treating depression in anxious patients and in treating the accompanying anxiety was rated as moderate. There was insufficient evidence to determine the comparative efficacy of second-generation antidepressants for low energy, psychomotor changes, melancholia, or somatization.
Pain: Key Points
Pooled results of four head-to-head studies in the systematic review and meta-analysis showed that improvement in pain scores was similar for paroxetine and duloxetine. Six studies provided mixed evidence for efficacy of active drugs, when compared with placebo, for treatment of accompanying pain. Six trials compared duloxetine with placebo; three of these reported statistically greater pain improvement in at least one duloxetine treatment arm. One study compared paroxetine with placebo and found a statistically greater improvement for paroxetine when compared with placebo. Overall, mean differences in pain scores between groups were small and may not be clinically meaningful. There was moderate-strength evidence that paroxetine and duloxetine had similar efficacy for treating chronic pain in patients with depression.
Insomnia: Key Points
Six head-to-head trials provided mixed evidence about the effects of antidepressants on insomnia in patients with depression. Two trials reported greater improvement in sleep scores for trazodone than for fluoxetine and venlafaxine; however, neither of these trials analyzed a subgroup of patients with insomnia. One trial found that sleep scores worsened with fluoxetine treatment but not with nefazodone treatment. One trial each found no statistically significant differences for patients taking the following medications: escitalopram or fluoxetine; fluoxetine, paroxetine, or sertraline; and fluoxetine or mirtazapine. Two trials of fluoxetine supplemented with eszopiclone and compared with fluoxetine alone in depressed patients with insomnia showed an improvement in sleep for those receiving concomitant eszopiclone. A placebo-controlled study of bupropion XL found a small, statistically significant improvement in insomnia in patients taking bupropion. There was only low-strength evidence that several second-generation antidepressants are equally effective at treating insomnia symptoms in patients with depression.
- Gartlehner G, Hansen RA, Morgan LC, et al. Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression: An Update of the 2007 Comparative Effectiveness Review. Comparative Effectiveness Review No. 46 (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I). Rockville, MD: Agency for Healthcare Research and Quality; December 2011. AHRQ Publication No. 12-EHC012-EF. Available at www.effectivehealthcare.ahrq.gov/secondgenantidep.cfm.
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