Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. Comparative Effectiveness Review Number 7

摘要

Depressive disorders such as major depressive disorder (MDD), dysthymia, and subsyndromal depression (including minor depression) may be serious disabling illnesses. MDD is the most prevalent, affecting more than 16 percent (lifetime) of U.S. adults. In 2000, the U.S. economic burden of depressive disorders was estimated to be $83.1 billion. More than 30 percent of these costs are attributable to direct medical expenses. Pharmacotherapy dominates the medical management of depressive disorders and may include first-generation antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) and more recently developed second-generation antidepressants. These second-generation treatments include selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). The mechanism of action of most of these agents is poorly understood. These drugs work, at least in part, through their effects on neurotransmitters such as serotonin, norepinephrine, or dopamine in the central nervous system. In general, the efficacy of first- and second-generation antidepressant medications is similar. However, first-generation antidepressants often produce multiple side effects that many patients find intolerable, and the risk for harm when taken in overdose or in combination with certain medications is high. Because of their relatively favorable side effect profile, the second-generation antidepressants play a prominent role in the management of patients with major depressive disorder and are the focus of this review. This report summarizes the available evidence on the comparative efficacy, effectiveness, and harms of 12 second-generation antidepressants: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine in treating patients with MDD, dysthymia, and subsyndromal depression. It also evaluates the comparative efficacy and effectiveness for maintaining remission and for treating accompanying symptoms such as anxiety, insomnia, or neurovegetative symptoms.