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Letter to the Editor

Likelihood to Be Helped or Harmed Can Assist in Clinical Decision-Making

Leslie Citrome, MD, MPH

Published: February 15, 2011

See the reply

Likelihood to Be Helped or Harmed Can Assist in Clinical Decision-Making

To the Editor: Gao and colleagues’ number-needed-to-treat analysis of the atypical antipsychotics was read with great interest.1 Perhaps the biggest public health impact is in the treatment of major depressive disorder (MDD), a common disorder for which the US Food and Drug Administration has approved 3 different antipsychotic agents to be used with antidepressants. The authors’ results are similar to what I have previously reported,2 and what remains striking is how commonly certain adverse events can be encountered: somnolence or sedation with quetiapine, weight gain with olanzapine, and akathisia with aripiprazole.

Number needed to treat for clinical response or remission can also be calculated,2 and balancing benefits and harms is at the focus of our clinical decision-making. Unfortunately, lower (more robust) NNT values for harms can be observed compared to NNT for response or remission. This translates to encountering certain adverse events more often than a therapeutic response. The ratio of likelihood to be helped to harmed (LHH) can be useful when examining these tradeoffs.2-4 This becomes crucial when accounting for patient preference in the hopes of enhancing adherence and the opportunity to maximize potential benefits of our interventions.


1. Gao K, Kemp DE, Fein E, et al. Number needed to treat to harm for discontinuation due to adverse events in the treatment of bipolar depression, major depressive disorder, and generalized anxiety disorder with atypical antipsychotics [published online ahead of print]. J Clin Psychiatry. Oct 19, 2010. doi:10.4088/JCP.09r05535gre PubMed

2. Citrome L. Adjunctive aripiprazole, olanzapine, or quetiapine for major depressive disorder: an analysis of number needed to treat, number needed to harm, and likelihood to be helped or harmed. Postgrad Med. 2010;122(4):39-48.PubMed doi:10.3810/pgm.2010.07.2174

3. Citrome L. Miracle pills for weight loss: what is the number needed to treat, number needed to harm and likelihood to be helped or harmed for naltrexone-bupropion combination? Int J Clin Pract. 2010;64(11):1462-1465.PubMed doi:10.1111/j.1742-1241.2010.02501.x

4. Citrome L, Kantrowitz J. Antipsychotics for the treatment of schizophrenia: likelihood to be helped or harmed, understanding proximal and distal benefits and risks. Expert Rev Neurother. 2008;8(7):1079-1091.PubMed doi:10.1586/14737175.8.7.1079

Leslie Citrome, MD, MPH

Author affiliations: New York University School of Medicine, New York. Potential conflicts of interest: Dr Citrome has been a consultant for Eli Lilly, GlaxoSmithKline, Janssen, Pfizer, Novartis, Merck, and Sunovion; has received grant/research support from AstraZeneca, Eli Lilly, Pfizer, and Sunovion; has received honoraria from AstraZeneca, Eli Lilly, Novartis, Merck, Pfizer, and Sunovion; has been a speakers or advisory board member for AstraZeneca, Eli Lilly, Novartis, Merck, Pfizer, and Sunovion; and holds a small number of shares in Bristol-Myers Squibb, Eli Lilly, Johnson & Johnson, Merck, and Pfizer. Funding/support: None reported.

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