PURPOSE: Several medications have recently been introduced for the treatmen
t of depression. We reviewed the literature to summarize their efficacy in
the treatment of depression in adult patients in primary care settings.
METHODS: We searched the literature published from 1980 to January 1998 usi
ng the Cochrane Collaboration Depression Anxiety and Neurosis Group's speci
alized registry of 8,451 clinical trials, references from trials and 46 per
tinent meta-analyses, and consultation with experts. We included randomized
controlled trials of at least 6 weeks' duration that measured clinical out
comes and compared one of 32 newer medications with another newer antidepre
ssant, an older antidepressant, a placebo, or a psychosocial intervention f
or the treatment of depressed patients in primary care settings. The primar
y outcome was response rate, defined as the proportion of patients experien
cing a 50% or greater improvement in depressive symptoms.
RESULTS: There were 28 randomized controlled trials involving 5,940 adult p
rimary care patients with major depression, depression requiring treatment,
dysthymia, or mixed anxiety depression. Newer agents, including selective
serotonin re-uptake inhibitors, serotonin norepinephrine inhibitors, revers
ible inhibitors of monoamine oxidase, and dopamine antagonists, were usuall
y compared with tricyclic agents. Average response rates were 63% for newer
agents, 35% for placebo, and 60% for tricyclic agents. Newer agents were s
ignificantly more effective than placebo [risk ratio = 1.6; 95% confidence
interval (CI), 1.2 to 2.1), but similar to tricyclic agents (risk ratio = 1
.0; 95% CI 0.9 to 1.1). Response rates were similar in the different types
of depressive disorders, except that two small trials in frail older patien
ts showed no significant effects of newer agents compared with placebo. Dro
pout rates as a result of adverse effects were 8% with newer agents and 13%
with tricyclic agents (P <0.05).
CONCLUSIONS: In primary care settings, newer antidepressants are more effec
tive than placebo and have similar efficacy compared with tricyclic agents
in the acute treatment of depression. Dropout rates as a result of adverse
effects are lower with newer compared with tricyclic agents. Future studies
should compare the effectiveness of different therapies among primary care
patients with less severe depression and greater medical and psychiatric c
omorbidity. Am J Med. 2000;108:54-64. (C)2000 by Excerpca Medica, Inc.