A systematic review of newer pharmacotherapies for depression in adults: Evidence report summary

Background: Depressive disorders are persistent, recurring illnesses that c ause great suffering for patients and their families. Purpose: To evaluate the benefits and adverse effects of newer pharmacother apies and herbal treatments for depressive disorders in adults and adolesce nts. Data Sources: English-language and non-English-language literature from 198 0 to January 1998 was identified from a specialized registry of controlled trials, meta-analyses, and experts. Study Selection: Randomized trials evaluating newer antidepressants (such a s serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibito rs, and St. John's wort) that reported clinical outcomes were selected. Data Extraction: Two persons independently abstracted data that were then s ynthesized descriptively; some data were pooled by using a random-effects m odel. Data Synthesis: Of 315 eligible trials, most evaluated antidepressants in a dults with major depression, were conducted among outpatients, and examined acute-phase treatment. Newer antidepressants were more effective than plac ebo for major depression (relative benefit, 1.6 [95% CI, 1.5 to 1.7]) and d ysthymia (relative benefit, 1.7 [CI, 1.3 to 2.3]). They were effective amon g older adults and primary care patients. Efficacy did not differ among new er agents or between newer and older agents. Hypericum (St. John's wort) wa s more effective than placebo for mild to moderate depression (risk ratio, 1.9 [Cl, 1.2 to 2.8]), but publication bias may have inflated the estimate of benefit. Newer and older antidepressants did not differ for overall disc ontinuation rates, but side effect profiles varied significantly. Data were insufficient for determining the efficacy of newer antidepressants for sub syndromal depression, depression with coexisting medical or psychiatric ill ness, or depression in adolescents. Conclusions: Newer antidepressants are clearly effective in treating depres sive disorders in diverse settings. Because of similar efficacy, both newer and older antidepressants should be considered when making treatment decis ions. Better information is urgently needed on the efficacy of newer antide pressants in patients with nonmajor depression and in special populations, including adolescents.