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Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis

Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD
JAMA. 2010;303(1):47-53. doi:10.1001/jama.2009.1943.
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Published online

Context Antidepressant medications represent the best established treatment for major depressive disorder, but there is little evidence that they have a specific pharmacological effect relative to pill placebo for patients with less severe depression.

Objective To estimate the relative benefit of medication vs placebo across a wide range of initial symptom severity in patients diagnosed with depression.

Data Sources PubMed, PsycINFO, and the Cochrane Library databases were searched from January 1980 through March 2009, along with references from meta-analyses and reviews.

Study Selection Randomized placebo-controlled trials of antidepressants approved by the Food and Drug Administration in the treatment of major or minor depressive disorder were selected. Studies were included if their authors provided the requisite original data, they comprised adult outpatients, they included a medication vs placebo comparison for at least 6 weeks, they did not exclude patients on the basis of a placebo washout period, and they used the Hamilton Depression Rating Scale (HDRS). Data from 6 studies (718 patients) were included.

Data Extraction Individual patient-level data were obtained from study authors.

Results Medication vs placebo differences varied substantially as a function of baseline severity. Among patients with HDRS scores below 23, Cohen d effect sizes for the difference between medication and placebo were estimated to be less than 0.20 (a standard definition of a small effect). Estimates of the magnitude of the superiority of medication over placebo increased with increases in baseline depression severity and crossed the threshold defined by the National Institute for Clinical Excellence for a clinically significant difference at a baseline HDRS score of 25.

Conclusions The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

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Figure 1. Study Selection and Data Acquisition
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Reasons for exclusion describe the first reason for exclusion that was encountered during the review process. Several articles had multiple reasons for exclusion. RCTs indicates randomized controlled trials; FDA, US Food and Drug Administration; ADM, antidepressant medication; HDRS, Hamilton Depression Rating Scale.

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Figure 2. Observed and Estimated Change in HDRS Scores Following Treatment With ADM and Placebo
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Circles represent observed (raw) mean change in depressive symptoms from intake to the end of treatment at each initial Hamilton Depression Rating Scale (HDRS) score for both the antidepressant medication (ADM) and placebo conditions. The size (area) of the circles is proportional to the number of data points that contributed to each mean. Regression lines represent estimates of change in depression symptoms from intake to end of treatment for ADM and placebo conditions as a function of baseline symptom severity. These regression lines were estimated from a model of the baseline severity × treatment interaction, controlling for the effects of the study from which the data originated. The National Institute for Clinical Excellence threshold for clinical significance (an HDRS point difference ≥3) was met for intake HDRS scores of 25 or greater, indicated by the blue line.

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