An evidence-based first consultation for depression: nine key messages

Bruce Arroll; Weng Yee Chin; Fiona Moir; Christopher Dowrick

doi:10.3399/bjgp18X695681

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Antidepressants can benefit patients with major depression, and a 10th key issue is which drugs should be used first-line
Tony Kendrick, Beth Stuart, Colin Newell, Andrew DeSilva and Sian Stephens

Published on: 14 August 2018

Published on: (14 August 2018)

Antidepressants can benefit patients with major depression, and a 10th key issue is which drugs should be used first-line
Tony Kendrick, Professor of Primary Care, University of Southampton
Other Contributors:
Beth Stuart, Associate Professor of Medical Statistics, University of Southampton

Colin Newell, Clinical Informatics Data Manager, University of Southampton

Andrew DeSilva, Foundation Doctor, University of Southampton

Sian Stephens, Foundation Doctor, University of Southampton
We agree with Arroll and colleagues¹ that GPs should think carefully before prescribing antidepressants, but they suggested even patients with severe depression are unlikely to benefit, citing a 2010 study² and ignoring the recent Lancet meta-analysis comparing 21 antidepressants and showing that all were more efficacious than placebo for major depression.³

We understand concerns about increasing GP antidepressant prescribing, and worry the widely reported meta-analysis might increase overall prescribing, rather than influence the relative use of different antidepressants, which was its aim.³ However, we have data to suggest its impact will not be to increase prescribing for new episodes.

We explored the effects of a 2009 meta-analysis by the same group, comparing 12 antidepressants,⁴ on GP prescribing using Clinical Practice Research Datalink data. The previous study stated that sertraline, having the most favourable balance between benefits, acceptability, and cost, might be the best initial choice.⁴ To explore the effects of this, we conducted time trend analyses of percentages of GP prescriptions for different antidepressants, modelled as an interrupted time series.

The figure shows percentages of antidepressants prescribed first-choice, for first-ever and recurrent episodes of depression, for citalopram, fluoxetine, sertraline, mirtazapine, and escitalopram. Time trend anal...
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We agree with Arroll and colleagues¹ that GPs should think carefully before prescribing antidepressants, but they suggested even patients with severe depression are unlikely to benefit, citing a 2010 study² and ignoring the recent Lancet meta-analysis comparing 21 antidepressants and showing that all were more efficacious than placebo for major depression.³

We understand concerns about increasing GP antidepressant prescribing, and worry the widely reported meta-analysis might increase overall prescribing, rather than influence the relative use of different antidepressants, which was its aim.³ However, we have data to suggest its impact will not be to increase prescribing for new episodes.

We explored the effects of a 2009 meta-analysis by the same group, comparing 12 antidepressants,⁴ on GP prescribing using Clinical Practice Research Datalink data. The previous study stated that sertraline, having the most favourable balance between benefits, acceptability, and cost, might be the best initial choice.⁴ To explore the effects of this, we conducted time trend analyses of percentages of GP prescriptions for different antidepressants, modelled as an interrupted time series.

The figure shows percentages of antidepressants prescribed first-choice, for first-ever and recurrent episodes of depression, for citalopram, fluoxetine, sertraline, mirtazapine, and escitalopram. Time trend analysis showed that, following the 2009 meta-analysis, sertraline rose significantly as a proportion of prescriptions by 0.9% per quarter-year (95% CI 0.7-1.1%) for first-ever episodes and 1.1% (0.8-1.4%) for recurrent episodes. Use of citalopram levelled off significantly, falling by 1.4% per quarter (0.4-2.4%) for first episodes, and 3.3% (0.9-5.7%) for recurrent, and use of fluoxetine continued to fall by 1.0% (0.5-1.4%) and 1.8% (0.8-2.7%) respectively.

^{Figure: Proportions of first-line antidepressants, prescribed by GPs for new and recurrent episodes of depression, which were for citalopram, fluoxetine, sertraline, mirtazapine and escitalopram, 2003 to 2013}

^{Includes data for 191,117 patients and 237,178 episodes of depression, across 142 practices in the Clinical Practice Research Datalink database. Of 237,178 episodes, 104,337 were first-ever episodes, 63% of which were treated with an antidepressant within the first 12 months of an episode start date; and 132,841 recurrent episodes, 73% of which were treated.}

Overall antidepressant prescribing did not increase, but remained at around 70% of cases diagnosed⁵. While prescriptions doubled from 2003-2013, this was not due to more people starting antidepressants, but to longer treatment, with a doubling of mean prescriptions per patient per year.⁵

An editorial accompanying the recent meta-analysis suggested three antidepressants with higher efficacy emerged as preferable first choices after factoring in acceptability: agomelatine, escitalopram, and vortioxetine.⁶ It will be interesting to see whether the use of these increases or not in the next few years, given their higher costs.

References

1. Arroll B, Chin WY, Moir F, Dowrick C. An evidence-based first consultation for depression: nine key messages. Br J Gen Pract 2018; 68:200–201. https://doi.org/10.3399/bjgp18X695681
2. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010; 303(1):47–53. https://doi.org/10.1001/jama.2009.1943
3. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet 2018; 391:1357-66. 2018 https://doi.org/10.1016/S0140-6736(17)32802-7
4. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatment meta-analysis. Lancet 2009; 373: 746–58. https://doi.org/10.1016/S0140-6736(09)60046-5
5. Kendrick T, Stuart B, Newell C, et al. Did NICE guidelines and the Quality Outcomes Framework change GP antidepressant prescribing in England? Observational study with time trend analyses 2003–2013. J Affective Disorders 2015; 186:171–7. https://doi.org/10.1016/j.jad.2015.06.052
6. Parikh SV, Kennedy SH. More data, more answers: picking the optimal antidepressant. Lancet 2018; 391:1333-1334. http://dx.doi.org/10.1016/S0140-6736(18)30421-5
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Competing Interests: None declared.