Assessing the Comparative Effectiveness of Antidepressant Therapies: A Prospective Clinical Practice Study
J Clin Psychiatry 2001;62(2):117-125
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Background: Although efficacy studies suggest
equal potency among antidepressant treatments, their
effectiveness in clinical practice appears more variable,
particularly in that the newer antidepressants may be less
effective in either more severe depression or the melancholic
subtype of depression. We pursue some factors that may impact the
effectiveness of antidepressant treatments in a clinical sample.
Method: A sample of 182 patients with DSM-IV
major depressive disorder was assessed at baseline and 12 months
later to establish treatments provided, identify patients who had
recovered from the index episode, and quantify likely treatment
determinants. Four systems for distinguishing patients with
melancholic and nonmelancholic depression were examined to assess
for differential effects of the antidepressant strategies across
Results: Multimodal therapy (commonly,
psychotherapy combined with an antidepressant drug) and patients'
frequent attribution of recovery to spontaneous improvement made
for difficulty in disentangling recovery determinants. After
excluding a spontaneous improvement component, electroconvulsive
therapy (ECT) and the irreversible monoamine oxidase inhibitors
(MAOIs) appeared to be the most effective therapies across the
sample, while the reversible inhibitor of monoamine oxidase-A
(RIMA) appeared to be the least effective. The distinct gradient
of suggested effectiveness of various strategies appeared to be
contributed to principally by the varied effectiveness of
alternate treatments across the melancholic subtype, whereby ECT,
tricyclic antidepressants, and MAOIs were the most effective, and
the selective serotonin reuptake inhibitors (SSRIs), RIMAs, and
antipsychotic drugs were much less effective. For the
nonmelancholic disorders, the effectiveness of SSRIs appeared to
be comparable with that of older antidepressants.
Conclusion: Although most patients
received a physical treatment, they commonly judged psychotherapy
and spontaneous improvement to be influential in their recovery.
Reasons for such attributions are worthy of clarifying studies.
Despite patients' concerns about the side effects and stigma of
ECT as well as the side effects associated with the older
antidepressants, these therapies were rated as more helpful by
patients--and were more strongly associated with recovery--than
the newer antidepressant drugs. Such overall results are
compatible with an earlier study undertaken by us involving an
independent sample and retrospective data. The overall gradient
is clarified by studying depressive subtypes, allowing an
important conclusion. Although the newer and older antidepressant
drugs may be of similar effectiveness in nonmelancholic
depression, the newer agents appear comparatively inferior for
the treatment of melancholia, findings that have clinical
implications and perhaps inform us about the pathogenesis of