Sertraline versus other antidepressive agents for depression

 

Abstract

Background

The National Institute for Health and Clinical Excellence clinical practice guideline on the treatment of depressive disorder recommended that selective serotonin reuptake inhibitors should be the first-line option when drug therapy is indicated for a depressive episode. Preliminary evidence suggested that sertraline might be slightly superior in terms of effectiveness.

Objectives

To assess the evidence for the efficacy, acceptability and tolerability of sertraline in comparison with tricyclics (TCAs), heterocyclics, other SSRIs and newer agents in the acute-phase treatment of major depression.

Search methods

MEDLINE (1966 to 2008), EMBASE (1974 to 2008), the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to July 2008. No language restriction was applied. Reference lists of relevant papers and previous systematic reviews were hand-searched. Pharmaceutical companies and experts in this field were contacted for supplemental data.

Selection criteria

Randomised controlled trials allocating patients with major depression to sertraline versus any other antidepressive agent.

Data collection and analysis

Two review authors independently extracted data. Discrepancies were resolved with another member of the team. A double-entry procedure was employed by two reviewers. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), acceptability (the number of patients who failed to complete the study) and tolerability (side-effects).

Main results

A total of 59 studies, mostly of low quality, were included in the review, involving multiple treatment comparisons between sertraline and other antidepressant agents. Evidence favouring sertraline over some other antidepressants for the acute phase treatment of major depression was found, either in terms of efficacy (fluoxetine) or acceptability/tolerability (amitriptyline, imipramine, paroxetine and mirtazapine). However, some differences favouring newer antidepressants in terms of efficacy (mirtazapine) and acceptability (bupropion) were also found. In terms of individual side effects, sertraline was generally associated with a higher rate of participants experiencing diarrhoea.

Authors' conclusions

This systematic review and meta-analysis highlighted a trend in favour of sertraline over other antidepressive agents both in terms of efficacy and acceptability, using 95% confidence intervals and a conservative approach, with a random effects analysis. However, the included studies did not report on all the outcomes that were pre-specified in the protocol of this review. Outcomes of clear relevance to patients and clinicians were not reported in any of the included studies.

 

Plain language summary

Sertraline versus other antidepressive agents for depression

Depression is the fourth leading cause of disease burden worldwide and is expected to show a rising trend over the next 20 years. Depression is associated with a marked personal, social and economic morbidity, loss of functioning and productivity, and creates significant demands on service providers in terms of workload. Although pharmacological and psychological interventions are both effective for major depression, antidepressant drugs remain the mainstay of treatment. During the last 20 years, selective serotonin reuptake inhibitors (SSRIs) have progressively become the most commonly prescribed antidepressants. Sertraline, one of the first SSRIs introduced in the market, is a potent and specific inhibitor of serotonin uptake into the presynaptic terminal, with a modest activity as inhibitor of dopamine uptake. In the present review we assessed the evidence for the efficacy, acceptability and tolerability of sertraline in comparison with all other antidepressants in the acute-phase treatment of major depression. Fifty-nine randomised controlled trials (about 10,000 participants) were included in the review. The review showed evidence of differences in efficacy, acceptability and tolerability between sertraline and other antidepressants, with meta-analyses highlighting a trend in favour of sertraline over other antidepressants, both in terms of efficacy and acceptability, in a homogeneous sample of clinical trials, using conservative statistical methods. The included studies did not report on all the outcomes that were pre-specified in the protocol of this review. Outcomes of clear relevance to patients and clinicians, in particular, patients and their carers' attitudes to treatment, their ability to return to work and resume normal social functioning, were not reported in the included studies. Nevertheless, based on currently available evidence, results from this review suggest that sertraline might be a strong candidate as the initial choice of antidepressant in people with acute major depression.

 

摘要

背景

Sertraline與其他抗憂鬱劑(antidepressive agents)在抗鬱上的比較

國家健康學會(The National Institute for Health)及臨床卓越臨床應用指導(Clinical Excellence clinical practice guideline)在憂鬱症的治療上建議:當藥物治療為憂鬱發作時的適應治療時, SSRI(selective serotonin reuptake inhibitors)應是第一線的選擇. 初步的證據建議sertraline也許在治療效果上較好.

目標

評估escitalopram 在療效上的證據,接受度及耐受性上與三環抗鬱劑TCAs(tricyclics),異環類(heterocyclics),其他SSRIs,及在重鬱症急性期較新的治療藥物比較.

搜尋策略

MEDLINE (1966年至2008年)，EMBASE(1974年至2008年) ， Cochrane Collaboration Depression，焦慮和神經症對照試驗註冊和Cochrane中央登記的對照試驗直到2008年7月。沒有限制語言。對相關參考文獻的清單和先前的系統評價進行了手工搜查。接觸了製藥公司和在這一領域的專家來進行資料的補充。

選擇標準

隨機對照試驗分配憂鬱症患者到sertraline與任何其他抗抑鬱劑組。

資料收集與分析

兩個審查作者獨立提取數據。有不一致的地方則由另一位小組成員來解決。雙重介入的程序是由兩個審查作者來擔任。提取的信息包括研究的特點，受試者的特點，介入措施的細節和結果方面的功效(有反應及緩解的病人數) ，可接受性(未完成研究的病人數)和耐受性(副作用) 。

主要結論

共有59個研究，其中大部分是低質量，但也包括在審查中，涉及多個治療比較sertraline和其他抗憂鬱劑。sertraline 的證據有利於一些其他抗抑鬱藥在急性期治療憂鬱症的效果，無論是療效(fluoxetine)或可接受性/耐受性(amitriptyline, imipramine, paroxetine and mirtazapine) 。但也發現，由療效(mirtazapine)和可接受度(bupropion)來看, 有些差異有利於新型抗憂鬱藥。在個別的副作用來看，sertraline較它組受試者經歷較高的腹瀉比例。

作者結論

這一系統性的審查和後設分析強調了無論在有效性和可接受性上, 傾向於sertraline優於其他抗憂鬱劑，這是使用95 ％信賴區間和保守的做法，以隨機效果分析。但是，接受審查的研究沒有報告所有在審查協議預先指定的結果。和病人及醫生相關的結果, 並沒有在接受審查的任何研究被報告出來。

翻譯人

本摘要由彰化基督教醫院廖慈凰翻譯。

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

總結

憂鬱症是全球第四大疾病負擔，並且預計在今後20年將出現上升的趨勢。憂鬱症與顯著的個人，社會和經濟病態有相關性，損失功能與產能，並對服務提供者創造了巨大的工作量。雖然藥理和心理介入都是對憂鬱症都有效，抗憂鬱藥物仍是主要治療。在過去20年中，selective serotonin reuptake inhibitors(SSRIs)已逐步成為最常用的抗憂鬱藥。Sertraline，第一個上市的SSRIs，是一種強力和專一的serotonin回收抑制劑，同時具有適度的多巴胺回收抑制。在本次審查中，我們評估了有效性的證據，比較sertraline和所有其他抗憂鬱藥在急性期治療憂鬱症的可接受性和耐受性。 59個隨機對照試驗(約10,000個受試者)列入了審查。審查證的據顯示sertraline和其他抗憂鬱藥效果，可接受性和耐受性的差異，且在一個同質臨床試驗中的樣本，使用保守的統計方法,後設分析強調了sertraline在有效性和可接受性皆優於其他抗憂鬱藥的趨勢。被納入審查的研究沒有報告所有在審查協議預先指定的結果。和病人及臨床醫生相關的結果, 特別是病人和他們的照顧者對治療的態度, 回到工作崗位的能力和恢復正常的社會功能,並沒有在研究中被報告出來。然而，根據現有證據，這一審查結果表明，sertraline在治療急性重度憂鬱症患者身上可能成為一個強有力的初始選擇。