PubMed · 16012921
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M Schmauss, T Messer. 2005. [Dysthymia].. https://doi.org/10.1055/s-2004-830141
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Reanalyses of placebo-controlled trials reveal an increased risk of suicidal ideations or parasuicidal acts in children and adolescents under treatment with selective serotonin reuptake inhibitors (SSRI) or other antidepressants. Although no completed suicide was shown, these findings are the more important because, with the exception of fluoxetine, an evidence base for the efficacy of antidepressants is weak or lacking in this age group. For adults, there is no reason to doubt that antidepressants help to reduce suicides by shortening depressive episodes and preventing recurrence. A general and pronounced suicide-inducing effect of SSRI or other antidepressants can largely be excluded. On the other hand, in some vulnerable patients the risk of suicidal acts can increase, especially during the first days of antidepressant treatment. There is no evidence that this risk is higher with SSRI than with other antidepressants or nonpharmacological treatments. Safety in case of overdose is a strong argument favouring newer antidepressants over tri- and tetracyclic antidepressants in outpatients with unclear suicidality. The current widespread public discussions concering the risks of antidepressants is a risk in itself because confidence in treatment, compliance, and help seeking behaviour may get influenced negatively.
BACKGROUND: It has been recommended that onset of antidepressant action be assessed using survival analyses with assessments taken at least twice per week. However, such an assessment schedule is problematic to implement. The present study assessed the feasibility of comparing onset of action between treatments using a categorical repeated measures approach with a traditional assessment schedule. METHOD: Four scenarios representative of antidepressant clinical trials were created by varying mean improvements over time. Two assessment schedules were compared within the simulated 8-week studies: (i) 'frequent' assessment--16 postbaseline visits (twice-weekly for 8 weeks); (ii) 'traditional' assessment--5 postbaseline visits (Weeks 1, 2, 4, 6, and 8). Onset was defined as a 20 per cent improvement from baseline, and had to be sustained at all subsequent assessments. Differences between treatments were analysed with a survival analysis (KM = Kaplan-Meier product limit method) and a categorical mixed-effects model repeated measures analysis (MMRM-CAT). RESULTS: More frequent assessments resulted in small reductions in empirical standard errors compared with traditional assessments for both analytic methods. More frequent assessments altered estimates of treatment group differences in KM such that power was increased when the difference between treatments was increasing over time, but power decreased when the treatment difference decreased over time. More frequent assessments had a minimal effect on estimates of treatment group differences in MMRM-CAT. The MMRM-CAT analysis of data from a traditional assessment schedule provided adequate control of type I error, and had power comparable to or greater than that with KM analyses of data from either a frequent or a traditional assessment schedule. CONCLUSION: In the scenarios tested in this study it was reasonable to assess treatment group differences in onset of action with MMRM-CAT and a traditional assessment schedule. Additional research is needed to assess whether these findings hold in data with drop-out and across definitions of onset.
This paper reviews recent advances in application of cognitive therapy (CBT) to a therapeutic problem in depression. Modern follow-up studies indicate that, in spite of the efficacy of pharmacotherapy, relapse and recurrence rates in some depressed patients remain high. This does not appear mainly due to failure to receive medication, but to reflect intractability of the disorder. In acute treatment, psychological treatments, although beneficial, are less cost-effective than antidepressants, due to high costs of therapists. Benefit which lasts longer, particularly if combined with medication, may therefore be particularly valuable. There have now been seven randomized controlled trials of cognitive therapy designed specifically to test relapse and recurrence prevention. All have shown significant benefit, which lasts beyond the cessation of therapy. The effect appears to be more on preventing symptom return than on lessening current symptoms, to summate well with continuation and maintenance antidepressant, and not to be due simply to enhanced medication adherence. Incorporation into routine clinical practice is now appropriate and recommendations are proposed.