Who benefits from antidepressants?
A new study published today in PLoS Medicine suggests that antidepressants only benefit some, very severely depressed patients.
"New generation" antidepressants, such as fluoxetine (Prozac) are widely prescribed for the treatment of clinical depression. However some studies have suggested that these drugs do not help the majority of depressed people get better by very much. Irving Kirsch, from the University of Hull, and his colleagues, studied this question in closer detail, looking at whether a patient's response to antidepressant therapy depends on how badly depressed they are to start out with.
Kirsch and colleagues used a technique called "meta-analysis", where they put together data on clinical benefit from all the trials submitted to the US Food and Drug Administration for four drugs: fluoxetine (Prozac), venlafaxine (Effexor), nefazodone (Serzone), and paroxetine (Seroxat / Paxil). (The researchers also wanted to include sertraline and citalopram, but couldn't find all the relevant data for those two drugs). By including data from unpublished as well as published trials, the researchers set out to avoid bias that might come from non-publication of disappointing findings.
When the data from all of these trials had been put together, the improvement in depression amongst patients receiving the trial drug, as compared to those receiving placebo (dummy tablets), was not clinically significant in mildly depressed patients or even in most patients who suffer from very severe depression. The benefit only seemed to be clinically meaningful for a small group of patients who were the most extremely depressed to start out with. This improvement seemed to come about because these patients did not respond as well as less depressed patients to placebo, rather than responding better to the drug.
Irving Kirsch, summarising the paper, says: "Although patients get better when they take antidepressants, they also get better when they take a placebo, and the difference in improvement is not very great. This means that depressed people can improve without chemical treatments."
Given these results, the researchers conclude that there is little reason to prescribe new-generation antidepressant medications to any but the most severely depressed patients unless alternative treatments have been ineffective
Citation: Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, et al. (2008) Initial severity and antidepressant benefits: A metaanalysis of data submitted to the Food and Drug Administration. PLoS Med 5(2): e45.
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Health inequities in the US have narrowed then widened over last four decades
The difference in health between rich and poor and between different racial/ethnic groups, as measured by rates of dying young and of infant deaths, shrank in the US from 1966 to 1980 then widened from 1980 to 2002, according to a new study in PLoS Medicine.
The study also found that if everyone in the US had experienced the same health gains as the most advantaged did from 1960 to 2002 (i.e. as the whites in the highest income groups), 14% of premature deaths among whites and 30% of premature deaths among people of color would have been prevented.
A debate has raged among public health experts in different countries as to whether disparities in health widen or narrow as overall mortality rates decline. Some research has found that as the overall population health has improved, the disparities in health between rich and poor and between different ethnic groups have narrowed. However, other research has shown that overall health gains mask worsening disparities - while rich, white Americans get healthier, the poor and those in ethnic minority groups either get sicker or else their health improves at a much slower pace.
In order to investigate changes in the magnitude of health inequities over time, Nancy Krieger (Harvard School of Public Health, Boston, MA, USA) and colleagues studied two common measures of population health: rates of premature mortality (dying before the age of 65 years) and of infant mortality (death before the age of 1 year). They used death statistics data from different US counties, which are routinely collected by US states and submitted to the federal government. They studied these mortality rates for counties at different income levels, for the total US population, and for whites versus people of color.
The finding that socioeconomic and racial/ethnic inequities in US premature mortality and infant death narrowed and then widened requires explanation, say Krieger and colleagues, "and refutes the view that improvements in population health by default entail growing or shrinking health disparities."
"Death is inevitable," say the authors, "but premature mortality is not."
Citation: Krieger N, Rehkopf DH, Chen JT, Waterman PD, Marcelli E, et al. (2008) The fall and rise of US inequities in premature mortality: 1960-2002. PLoS Med 5(2): e46.
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Todd R. Datz
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Harvard School of Public Health
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