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Sunday, January 10, 2010

Antidepressants and Depression Severity

Only Most Depressed Benefit From Antidepressants

Books such as 'Prozac Nation' bear witness to the fact that antidepressant medications are among the most widely prescribed and taken drugs in the United States, and worldwide. Now a meta-analysis published in this week's JAMA raises the question of who really benefits from such medications.
Antidepressant Drug Effects and Depression Severity pooled data from 6 studies and included 718 adult patients. Information on depression severity was gleaned using the Hamilton Depression Rating Scale, a more quantitative, objective measure of how badly someone is affected by their depression than either reports by the patient or clinical impressions. The researchers found that the people who received the most benefit from antidepressant medications were those who were more depressed to begin with. Those with only mild or moderate depression didn't gain the same relief or any relief at all. It therefore appears that only those with severe depression should really use these drugs.

Rick and I discuss in the podcast the fact that the majority of people with depression fall into the mild or moderate category, so millions of folks who take antidepressant medications are unlikely to benefit from them. Since these drugs, like all drugs, have a host of side effects, it appears that some reanalysis is in order.

How can such a situation develop? Rick explains that when clinical trials are done the most severely affected patients are recruited for study, since presumably the drugs will show a benefit in those who are the sickest if a benefit is seen at all. Yet studies haven't been done to establish efficacy in those with less severe depression, and now it seems there isn't a benefit.

Does this mean that the legions of people with mild to moderate depression are out of luck with regard to therapy? No, but instead of antidepressant medications they could choose to undergo treatments such as cognitive behavioral therapy, which has been shown to be effective in this population. And then they could avoid things like sexual dysfunction that are also known to occur with the most commonly prescribed medications for depression.

Other topics this week include strategies to reduce surgical site infections in NEJM, the relationship between cigarette smoking and type 2 diabetes in Annals of Internal Medicine, and changes in the adult immunization schedule in the same journal. Until next week, y'all live well.

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