This is not the most recent version of the article. View current version (17 JUL 2013)

Intervention Review

Fluoxetine versus other types of pharmacotherapy for depression

  1. Andrea Cipriani1,*,
  2. Paulo Brambilla2,
  3. Toshi A Furukawa3,
  4. John Geddes4,
  5. Manuela Gregis1,
  6. Matthew Hotopf5,
  7. Lara Malvini1,
  8. Corrado Barbui1

Editorial Group: Cochrane Depression, Anxiety and Neurosis Group

Published Online: 19 OCT 2005

Assessed as up-to-date: 22 AUG 2005

DOI: 10.1002/14651858.CD004185.pub2


How to Cite

Cipriani A, Brambilla P, Furukawa TA, Geddes J, Gregis M, Hotopf M, Malvini L, Barbui C. Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004185. DOI: 10.1002/14651858.CD004185.pub2.

Author Information

  1. 1

    University of Verona, Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, Verona, Italy

  2. 2

    University of Udine, Department of Psychological Medicine, Udine, Italy

  3. 3

    Nagoya City University Graduate School of Medical Sciences, Department of Psychiatry & Cognitive-Behavioral Medicine, Nagoya, Aichi, Japan

  4. 4

    University of Oxford/Warneford Hospital, Department of Psychiatry, Oxford, UK

  5. 5

    The Institute of Psychiatry, Department of Psychological Medicine, London, UK

*Andrea Cipriani, Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Policlinico "G.B.Rossi", Piazzale L.A. Scuro, 10, Verona, 37134, Italy. andrea.cipriani@univr.it. andrea.cipriani@psych.ox.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 19 OCT 2005

SEARCH

This is not the most recent version of the article. View current version (17 JUL 2013)

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Depression is common in primary care and it is associated with marked personal, social and economic morbidity, and creates significant demands on service providers in terms of workload. Treatment is predominantly pharmaceutical or psychological. Fluoxetine, the first of a group of antidepressant (AD) agents known as selective serotonin reuptake inhibitors (SSRIs), has been studied in many randomised controlled trials (RCTs) in comparison with tricyclic (TCA), heterocyclic and related ADs, and other SSRIs. These comparative studies provided contrasting findings. In addition, systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to fluoxetine alone. The present systematic review assessed the efficacy and tolerability profile of fluoxetine in comparison with TCAs, SSRIs and newer agents.

Objectives

To determine the efficacy of fluoxetine, compared with other ADs, in alleviating the acute symptoms of depression, and to review its acceptability.

Search methods

Relevant studies were located by searching the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR), the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (1966-2004) and Embase (1974-2004). Non-English language articles were included.

Selection criteria

Only RCTs were included. For trials which have a crossover design only results from the first randomisation period were considered.

Data collection and analysis

Data were independently extracted by two reviewers using a standard form. Responders to treatment were calculated on an intention-to-treat basis: drop-outs were always included in this analysis. When data on drop-outs were carried forward and included in the efficacy evaluation, they were analysed according to the primary studies; when dropouts were excluded from any assessment in the primary studies, they were considered as treatment failures. Scores from continuous outcomes were analysed including patients with a final assessment or with the last observation carried forward. Tolerability data were analysed by calculating the proportion of patients who failed to complete the study and who experienced adverse reactions out of the total number of randomised patients. The primary analyses used a fixed effects approach, and presented Peto Odds Ratio (Peto OR) and Standardised Mean Difference (SMD).

Main results

On a dichotomous outcome fluoxetine was less effective than dothiepin (Peto OR: 2.09, 95% CI 1.08 to 4.05), sertraline (Peto OR: 1.40, 95% CI 1.11 to 1.76), mirtazapine (Peto OR: 1.64, 95% CI 1.01 to 2.65) and venlafaxine (Peto OR: 1.40, 95% CI 1.15 to 1.70). On a continuous outcome, fluoxetine was more effective than ABT-200 (Standardised Mean Difference (SMD) random effects: - 1.85, 95% CI - 2.25 to - 1.45) and milnacipran (SMD random effects: - 0.38, 95% CI - 0.71 to - 0.06); conversely, it was less effective than venlafaxine (SMD random effect: 0.11, 95% CI 0.00 to 0.23), however these figures were of borderline statistical significance.
Fluoxetine was better tolerated than TCAs considered as a group (Peto OR: 0.78, 95% CI 0.68 to 0.89), and was better tolerated in comparison with individual ADs, in particular than amitriptyline (Peto OR: 0.64, 95% CI 0.47 to 0.85) and imipramine (Peto OR: 0.79, 95% CI 0.63 to 0.99), and among newer ADs than ABT-200 (Peto OR: 0.21, 95% CI 0.10 to 0.41), pramipexole (Peto OR: 0.20, 95% CI 0.08 to 0.47) and reboxetine (Peto OR: 0.61, 95% CI 0.40 to 0.94).

Authors' conclusions

There are statistically significant differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain, and no definitive implications for clinical practice can be drawn. From a clinical point of view the analysis of antidepressants' safety profile (adverse effect and suicide risk) remains of crucial importance and more reliable data about these outcomes are needed. Waiting for more robust evidence, treatment decisions should be based on considerations of clinical history, drug toxicity, patient acceptability, and cost. We need for large, pragmatic trials, enrolling heterogeneous populations of patients with depression to generate clinically relevant information on the benefits and harms of competitive pharmacological options. A meta-analysis of individual patient data from the randomised trials is clearly necessary.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Fluoxetine compared with other antidepressants for depression

The efficacy and tolerability of fluoxetine was compared to other antidepressants (tricyclics, heterocyclics and newer antidepressants) for the acute treatment of depressive illness. One hundred thirty-two randomised controlled trials were identified. Pooling the results from the trials, statistically significant differences in efficacy and in tolerability were found between fluoxetine and some antidepressants. However, it is difficult to draw clear clinically meaningful conclusions and more reliable data about antidepressants' safety profile are needed. Without more robust evidence, the researchers suggest that treatment decisions are to be based on considerations of drug toxicity, patient acceptability, and cost.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

Fluoxetine及其他種類藥物治療憂鬱症的比較

憂鬱症是一種在臨床照護上常見的疾病,且它會造成個人、社會及經濟病態,造成照護提供者工作量明顯增加。治療主要是以藥物或心理治療,選擇性血清回收抑制抗鬱劑(SSRIs)的第一個藥物Fluoxetine,已在很多隨機對照臨床試驗中被使用來和三環類抗鬱劑(TCA),多環類抗鬱劑,相關的其他抗鬱劑或者其他的選擇性血清回收抑制抗鬱劑(SSRIs)來做比較研究。這些比較研究提供了對比的結果。除此之外,有系統的回顧隨機對照臨床試驗一直視選擇性血清回收抑制抗鬱劑(SSRIs)為一組,而證據適用於這組藥物未必單獨適用於fluoxetine,此系統回顧研究評估fluoxetine和三環類抗鬱劑(TCA),其他選擇性血清回收抑制抗鬱劑(SSRIs)及新抗鬱劑比較的效用及耐受性資料。

目標

以確認fluoxetine和其他抗鬱劑比較的效用,解除急性憂鬱症狀的效果及回顧其備接受度。

搜尋策略

相關試驗是從Cochrane Collaboration Depression,Anxiety and Neurosis Controlled Trials Register (CCDANCTR), the Cochrane Central Register of Controlled Trials (CENTRAL), Medline(1966年到2004年)及Embase(1974年到2004年)搜尋。非英文的文章也會被納入。

選擇標準

只有隨機對照試驗會被納入,試驗設計若是用互換設計則只有在第一次被隨機分配試驗的結果會被採納。

資料收集與分析

資料由兩位回顧作者使用標準化模式獨立擷取,對治療有反應者是以治療意向分析法為基礎,退出試驗的個案也會被納入分析,當退出試驗個案資料被進一步使用且納入在效用評估時,他們會根據原始的設計組別被分析,當試驗個案從初期試驗的任何評估被排除,他們被視為治療失敗,連續性的結果的分數包括患者的最後評估,或者以最近一次觀察進行分析。耐受性數據分析是看整體隨機病人中,多少比例的病人未能完成研究以及多少比例經驗了不良反應。基本的分析是使用固定效應模式,以Peto勝算比(PetoOR)及標準平均差異(SMD)來呈現。

主要結論

在二分法結果中,fluoxetine比dothiepin效果不佳(PetoOR:2.09,95%CI 1.08 to 4.05),比sertraline效果不佳(PetoOR:1.40,95%CI 1.11 to 1.76),比mirtazapine效果不佳(PetoOR:1.64,95%CI 1.01 to 2.65),比venlafaxine效果不佳(Peto OR:1.40,95%CI 1.15 to 1.70)。在連續性資料結果上,fluoxetine優於ABT200(標準平均差異(SMD)隨機效應:  1.85,95%CI  2.25 to  1.45),優於milnacipran(標準平均差異(SMD)隨機效應:  0.38,95% CI  0.71 to  0.06),但相對的比venlafaxine效果不佳(標準平均差異(SMD)隨機效應: 0.11,95% CI 0.00 to 0.23),然而這些數字為邊緣統計學意義。Fluoxetine比三環類抗鬱劑(TCA)這一類別藥物有較佳的耐受性(Peto OR:0.78,95%CI 0.68 to 0.89),個別的比較也是有較佳的耐受性,特別是amitriptyline(Peto OR:0.64,95%CI 0.47 to 0.85)及imipramine(Peto OR:0.79,95%CI 0.63 to 0.99),在新的抗鬱劑中,比ABT200(Peto OR:0.21,95%CI 0.10 to 0.41),pramipexole(Peto OR:0.20,95%CI 0.08 to 0.47)及reboxetine(Peto OR: 0.61,95%CI 0.40 to 0.94)有較佳的耐受性。

作者結論

在效用及耐受性方面,fluoxetine跟其他特定抗鬱劑,有統計上顯著的差異,但這些差異在臨床上的意義還不清楚,並無法得出確切臨床操作的影響,從臨床角度看抗鬱劑安全性的分析(副作用及自殺風險)這些成果是必要的,仍然是關鍵重要和較可靠的數據。等待更有力的證據,處理決定應當根據考慮臨床病史,藥物毒性,病人的可接受度和成本。我們需要大型的,務實的試驗,納入異質性憂鬱症患者產生臨床相關資料,關於比較藥理選擇的優點及缺點。從隨機試驗個案做統合分析顯然是必要的。

翻譯人

本摘要由彰化基督教醫院許文郁翻譯。

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

總結

在急性治療憂鬱疾病,fluoxetine及其他抗鬱劑(三環類、異環類及新抗鬱劑)效用及耐受性的比較。一共找到132個隨機控制試驗,把這些試驗結果統合起來,在效用及耐受性方面,fluoxetine跟一些抗鬱劑,有統計上顯著的差異,然而,難以得出明確的臨床有意義的結論,更可靠關於抗鬱劑的安全性數據是必要的。如果沒有更有力的證據,研究人員認為,治療的決定是基於考慮藥物的毒性,患者對藥物接受性和成本。