Antidepressants versus placebo for people with bulimia nervosa

  • Review
  • Intervention

Authors


Abstract

Background

Bulimia Nervosa (BN) represents an important public health problem and is related to serious morbidity and even mortality. This review attempted to systematically evaluate the use of antidepressant medications compared with placebo for the treatment of bulimia nervosa.

Objectives

The primary objective of this review was to determine whether using antidepressant medications was clinically effective for the treatment of bulimia nervosa.

The secondary objectives were:
(i) to examine whether there was a differential effect for the various classes/types of antidepressants with regard to effectiveness and tolerability
(ii) to test the hypothesis that the effect of antidepressants on bulimic symptoms was independent of its effect on depressive symptoms

Search methods

(1) electronic searches of MEDLINE (1966 to December 2002), EMBASE (1980-December 2002) , PsycINFO (to December 2002), LILACS & SCISEARCH (to 2002)
(2) the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register - ongoing
(3) inspection of the references of all identified trials
(4) contact with the pharmaceutical companies and the principal investigator of included trials
(5) inspection of the International Journal of Eating Disorders - ongoing

Selection criteria

Inclusion criteria: every randomised, placebo-controlled trial in which antidepressant medications were compared to placebo to reduce the symptoms of bulimia nervosa in patients of any age or gender.
Quality criteria: reports were considered adequate if they were classified as A or B according to the Cochrane Manual. The Jadad scale, with a cut off of 2 points, was applied to check the validity of the above referred criterion but was not used as an inclusion criterion.

Data collection and analysis

Data were extracted independently by two reviewers for each included trial. Dichotomous data were evaluated by the relative risk with 95% confidence intervals (CI) around this measure, based on the random effects model; continuous data were evaluated by the standardised mean difference with the 95% CI. NNT was calculated using the inverse of the absolute risk reduction.

Main results

Currently the review includes 19 trials comparing antidepressants with placebo: 6 trials with TCAs (imipramine, desipramine and amitriptyline), 5 with SSRIs (fluoxetine), 5 with MAOIs (phenelzine, isocarboxazid, moclobemide and brofaromine) and 3 with other classes of drugs (mianserin, trazodone and bupropion). Similar results were obtained in terms of efficacy for these different groups of drugs. The pooled RR for remission of binge episodes was 0.87 (95% CI 0.81-0.93; p<0,001) favouring drugs. The NNT for a mean treatment duration of 8 weeks, taking the non-remission rate in the placebo controls of 92% as a measure of the baseline risk was 9 (95% CI 6 - 16). The RR for clinical improvement, defined as a reduction of 50% or more in binge episodes was 0.63 (95% CI 0.55-0.74) and the NNT for a mean treatment duration of 9 weeks was 4 (95% CI 3 - 6), with a non-improvement rate of 67% in the placebo group. Patients treated with antidepressants were more likely to interrupt prematurely the treatment due to adverse events. Patients treated with TCAs dropped out due to any cause more frequently that patients treated with placebo. The opposite was found for those treated with fluoxetine, suggesting it may be a more acceptable treatment. Independence between antidepressant and anti-bulimic effects could not be evaluated due to incomplete published data.

Authors' conclusions

The use of a single antidepressant agent was clinically effective for the treatment of bulimia nervosa when compared to placebo, with an overall greater remission rate but a higher rate of dropouts. No differential effect regarding efficacy and tolerability among the various classes of antidepressants could be demonstrated.

摘要

背景

抗憂鬱劑與安慰劑治療暴食症的比較

暴食症是一重要的公衛議題,與嚴重的發病甚至死亡有關. 此文獻回顧意圖系統性地評估使用抗憂鬱劑來治療暴食症與安慰劑的比較.

目標

此文獻回顧的第一目標為究竟在臨床上使用抗憂鬱劑來治療暴食症是否有療效. 第二目標為:(i)不同種類的抗憂鬱劑的療效與耐受性是否有差別(ii)檢驗如下的假說:抗憂鬱劑對暴食症症狀的改善是獨立於憂鬱症狀的

搜尋策略

(1)搜尋MEDLINE(1966年至2002年12月), EMBASE (1980年至2002年12月), PsycINFO (至2002年12月), LILACS & SCISEARCH (至2002年)(2) 考科藍登錄系統

選擇標準

納入標準:隨機,安慰劑控制試驗,與安慰劑相較,抗憂鬱劑用來減低暴食症症狀,不論任何年紀. 品質標準: 根據考科藍手冊的分類等級為A或B的報告皆被認為是適切的. 運用Jaded Scale來確定上述所提標準的有效性,切分點為2分,但這非納入標準.

資料收集與分析

每一篇納入的試驗資料皆由兩位文獻回顧者獨立摘取. 二元資料由95%信賴區間相對風險來評估,這是以隨機效應模式為基礎;連續性資料則是以標準化平均差來評估. 需要被治療的病人數(NNT)以絕對風險降低之倒數來計算.

主要結論

此文獻回顧共納入19個試驗,比較了抗憂鬱劑與安慰劑的差別:有6篇是三環抗鬱劑(imipramine, desipramine and amitriptyline), 5篇是選擇性血清素回收抑制劑(fluoxetine), 5篇是單胺抑制劑(phenelzine, isocarboxazid, moclobemide and brofaromine).3篇是其他種類的藥物(mianserin, trazodone and bupropion)這些不同種類的藥物我們藉由評估有效性來得到相似的結果. Similar results were obtained in terms of efficacy for these different groups of drugs. 暴食發作緩解的pooled RR為0.87 (95% CI 0.81 – 0.93; p<0,001),此結果傾向藥物使用. 將安慰劑那一組的無緩解率92%作為基礎風險的測量,平均治療時間為8週的NNT為9(95% CI 6  16),臨床改善的RR為0.63(95% CI 0.55 – 0.74),(臨床改善定義為減低50%以上的暴食發作),平均治療期間9週的NNT為4(95% CI 3  6),而安慰劑那一組的未改善率為67%. 接受抗鬱劑治療的病人較容易因為副作用而提早退出治療. 接受三環抗鬱劑比安慰劑哪一組更常因任何原因退出治療. 抗憂鬱劑與抗暴食效果間的獨立性因不完整的發表資料,所以無法評估.A

作者結論

與安慰劑相較,使用單一抗鬱劑來治療暴食症在臨床上是有效的,整體的緩解率更好,但也有較高的退出率. 就不同種類間的抗鬱劑的有效性與耐受性沒有差異效果可被證明

翻譯人

本摘要由彰化基督教醫院李冠瑩翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

當與安慰劑相較,以抗鬱劑治療暴食症是有效的,有著整體更佳的緩解率,但退出率也較高

Plain language summary

Antidepressants compared with placebo for bulimia nervosa

Individual antidepressants are effective for the treatment of bulimia nervosa when compared to placebo treatment, with an overall greater remission rate but a higher rate of dropouts.

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