Guideline recommendations for long-term treatment of depression with antidepressants in primary care—a critical review

Abstract

Background: Long-term treatment with antidepressants is considered effective in preventing recurrence of major depressive disorder (MDD). It is unclear whether this is true for primary care. Objectives: We investigated whether current guideline recommendations for long-term treatment with antidepressants in primary care are supported by evidence from primary care. Methods: Data sources for studies on antidepressants: PubMed, Cochrane Library, Embase, PsycInfo, Cinahl, articles from reference lists, cited reference search. Selection criteria: adults in primary care, continuation or maintenance treatment with antidepressants, with outcome relapse or recurrence, (randomized controlled) trial/naturalistic study/review. Limits: published before October 2009 in English. Results: Thirteen depression guidelines were collected. These guidelines recommend continuation treatment with antidepressants after remission for all patients including patients from primary care, and maintenance treatment for those at high risk of recurrence. Recommendations vary for duration of treatment and definitions of high risk. We screened 804 literature records (title, abstract), and considered 27 full-text articles. Only two studies performed in primary care addressed the efficacy of antidepressants in the long-term treatment of recurrent MDD. A double-blind RCT comparing mirtazapine (n = 99) and paroxetine (n = 98) prescribed for 24 weeks reported that in both groups 2 patients relapsed. An open study of 1031 patients receiving sertraline for 24 weeks, who were naturalistically followed-up for up to two years, revealed that adherent patients had a longer mean time to relapse.

Conclusions: No RCTs addressing the efficacy of maintenance treatment with antidepressants as compared to placebo were performed in primary care. Recommendations on maintenance treatment with antidepressants in primary care cannot be considered evidence-based.

Key words::

• Depression
• primary care
• antidepressants
• continuation treatment
• maintenance treatment

Declaration of interests: E Piek: none declared. K van der Meer: none declared.

WA Nolen: Grants: Netherlands Organisation for Health Research and Development, Stanley Medical Research Institute, Astra Zeneca, Eli Lilly, Glaxo SmithKline, Wyeth; Honoraria/Speaker's fee: Astra Zeneca, Eli Lilly, Pfizer, Servier, Wyeth; Advisory boards: Astra Zeneca, Cyberonics, Eli Lilly, Glaxo SmithKline, Pfizer, Servier.

Appendix I

Search strategy

In general

Title screening screened on:

Focus: Treatment with antidepressants and outcome of depression.

Type of study (if mentioned in title): Clinical trial; randomized controlled trial; observational/naturalistic study; review/meta-analysis.

Population (if mentioned in title): Not only elderly people, no children or adolescents, not people with (specific) comorbidity.

Abstract selection and eligibility criteria:

P: Primary care patients, adults (no children/adolescents, not only elderly people (>64 years of age)).

I: Continuation and/or maintenance treatment with antidepressant drugs in primary care.

C: Placebo other antidepressants or no comparison.

O: Relapse/recurrence of depression.

S: Study design: Randomized controlled trial; controlled trial; open trial; clinical trial; naturalistic study; (systematic) review. Duration at least six months.

Pubmed

Depressive disorder, major (Mesh).

Antidepressive agents (Mesh);

(‘Primary Health Care’ [Mesh] OR ‘Physicians, Family’ [Mesh] OR ‘Family Practice’ [Mesh]) OR ‘primary care’ OR ‘general care’ OR ‘general health care’ OR ‘general practice’ OR ‘general practitioner’.

Limits:

Searched until 1 October 2009.

Articles in English.

Ages 19–64.

PsycInfo

((DE ‘Major Depression’) and (DE ‘Antidepressant Drugs’))

((DE ‘Primary Health Care’ or DE ‘Primary Mental Health Prevention’) or (DE ‘Family Medicine’ or DE ‘Family Physicians’)) or (DE ‘General Practitioners’) or ‘primary care’ or ‘general practice’ or ‘general care’ or ‘family practice’.

Limits: 1900–2009 (until 1 October).

Language: English.

Only humans.

Adults (18 and older).

Cochrane

Depressive disorder, major (Mesh).

Antidepressive agents (Mesh).

(‘Physicians, Family’ [Mesh] OR ‘Family Practice’ [Mesh]) OR ‘primary care’ OR ‘primary health care’ [Mesh] OR ‘general practice’ OR ‘general health care’ OR ‘general care’ OR ‘general practitioner’.

No limits (searched on 29 October 2009).

All articles reviews published after 1 October 2009 were excluded, just like everything not in English, research on animals, or ages only younger than 18 or older than 64 (children or elderly people). Also economic evaluations were excluded.

Embase

‘Major depression’/exp AND ‘antidepressant agent’/exp.

‘Primary health care’/exp OR ‘family medicine’/exp OR ‘general practice’/exp OR ‘general practitioner’/exp OR ‘family physician’ OR ‘family practice’ OR ‘primary care’ OR ‘primary health care’ OR ‘general health care’ OR ‘general care’.

Limits:

Searched until 1 October 2009.

Articles in English.

Ages 18–64.

Embase only.

Explosion, free text.

Cinahl

(MH ‘Antidepressive Agents’.)

(MH ‘Depression’.)

‘General health care’ or (MH ‘Physicians, Family’) or (MH ‘Primary Health Care’) or ‘primary care’ or ‘family medicine’ or ‘general practice’ or ‘general practitioner’ and ‘general care’ or ‘family practice’.

Limits:

(Explode antidepressive agents and depression.)

Publication January 1900 until September 2009.

Language: English.

All adult.