Efficacy of Bupropion and the Selective Serotonin Reuptake Inhibitors in the Treatment of Major Depressive Disorder With High Levels of Anxiety (Anxious Depression): A Pooled Analysis of 10 Studies
J Clin Psychiatry 2008;69(8):1287-1292
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Objective: The goal of this work was to
compare the efficacy of the norepinephrine and
dopamine reuptake inhibitor bupropion with the selective
serotonin reuptake inhibitors (SSRIs) in the
treatment of major depressive disorder with high levels
of anxiety (anxious depression).
Method: Ten double-blind, randomized
studies from 1991 through 2006 were combined (N = 2122). Anxious depression was defined as a
17-item Hamilton Rating Scale for Depression
(HAM-D-17) anxiety-somatization factor score >= 7.
Results: Among patients
with anxious depression (N = 1275), response rates were greater
following SSRI than bupropion treatment according to
the HAM-D-17 (65.4% vs. 59.4%, p = .03) and the Hamilton Rating Scale for Anxiety (61.5%
vs. 54.5%, p = .03). There was also a greater
reduction in HAM-D-17 mean ± SD scores (-14.1 ± 7.6 vs.
-13.2 ± 7.9, p = .03) and a trend toward
statistical significance for a greater reduction in
HAM-A mean ± SD scores (-10.5 ± 7.4 vs. -9.6 ± 7.6, p
= .05) in favor of SSRI treatment among patients
with anxious depression. There was no statistically
significant difference in efficacy between
bupropion and the SSRIs among patients with
moderate/low levels of anxiety.
Conclusions: There appears to be a modest
advantage for the SSRIs compared to bupropion in
the treatment of anxious depression (6% difference
in response rates). Using the
number-needed-to-treat (NNT) statistic as 1 indicator of clinical
significance, nearly 17 patients would need to be
treated with an SSRI than with bupropion in order to
obtain 1 additional responder. This difference falls
well above the limit of NNT = 10, which was
suggested by the United Kingdom's National Institute
of Clinical Excellence. Nevertheless, the present
work is of theoretical interest because it provides
preliminary evidence suggesting a central role for
serotonin in the regulation of symptoms of negative
affect such as anxiety.