Antidepressants for depressed elderly

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Abstract
Depression is a relatively common experience in older adults. The syndrome is associated with considerable distress, morbidity and service commitment. Approximately two thirds of patients presenting with severe forms will respond to antidepressant treatment and the last twenty years has witnessed a great increase in the number of these drugs. Older, frail people are particularly vulnerable to side effects. The aims of this review were to examine the efficacy of antidepressant classes, to compare the withdrawal rates associated with each class and describe the side effect profile of antidepressant drugs for treating depression in patients described as elderly, geriatric, senile or older adults, aged 55 or over. The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR‐Studies) was searched (2003‐08‐13). Reference lists of relevant papers and previous systematic reviews were hand searched for published reports and citations of unpublished studies. Only randomised controlled trials were included. Trials had to compare at least two active antidepressant drugs in the treatment of depression. Reviewers extracted data independently. In examining efficacy, the reviewers assumed that people who died or dropped out had no improvement. Withdrawal rates irrespective of cause and specifically due to side effects were compared between drug classes. Relative risk (RR) for dichotomous data and weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Qualitative side effect data were reported in terms of ratios of side effects and percentage of patients experiencing specific side effects. A total of 32 trials provided data for inclusion in the review in terms of efficacy, withdrawal and side effect analysis. We were unable to find any differences in efficacy when comparing classes of antidepressants. Tricyclic antidepressants (TCAs) compared less favourably with selective serotonin reuptake inhibitors (SSRIs) in terms of numbers of patients withdrawn irrespective of reason (RR: 1.23, CI 1.05 to 1.43) and number withdrawn due to side effects (RR: 1.36, CI 1.09 to 1.70). Further analyses demonstrated that TCA related antidepressants had similar withdrawal rates to SSRIs irrespective of reason of withdrawal (RR: 1.49, CI 0.74 to 2.98) or withdrawal due to side effects (RR: 1.07, CI 0.43 to 2.70). The qualitative analysis of side effects showed a small increased profile of gastro‐intestinal and neuropsychiatric side effects associated with classical TCAs. Our findings suggest that SSRIs and TCAs are of the same efficacy. However, we have found some evidence suggesting that TCA related antidepressants and classical TCAs have different side effect profiles and are associated with differing withdrawal rates when compared with SSRIs. The review suggests that classical TCAs are associated with a higher withdrawal rate due to side effect experience, although these results must be interpreted with caution due to the heterogeneity of the drugs and patient populations. 抗憂鬱劑治療憂鬱的老年人 在年紀大的成人中,憂鬱是一個常見的經驗. 這個症狀跟相當的痛苦,致病率和服務委任相關. 將近三分之二表現出嚴重形式的病人將會對抗憂鬱劑治療有反應而過去20年見證到這些藥物的數量有明顯的增加. 年長,身體虛弱的病人特別容易感受到這些副作用. 這個回顧的目標在於調查在治療被描述為年長的,老年人,老邁的或是較老的,年紀55歲或是大於55歲抗憂鬱劑類別的效果,去比較各個類別的退出率和描述抗憂鬱劑副作用的特性 The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTRStudies)被搜索(2003 – 08 – 13). 手動搜索恰當文獻的參考文獻列表和之前系統性的回顧來找出發表過的報告和未發表過研究的引用 只有隨機對照試驗被納入. 試驗必須比較至少兩種現有的抗憂鬱劑藥物來治療憂鬱 回顧者獨立地擷取數據. 為了檢視效果,回顧者假設死亡和退出的病患為無改善. 比較藥物類別與類別之間和原因無關的退出率和特別因副作用引起的退出率. 為了二分數據,用95%信賴區間(95% confidence intervals)計算了相關危險(Relative risk)和為了連續數據計算了加權平均差異(weighted mean difference). 定性的副作用以副作用的比值和病患經驗特別副作用的百分比來報告. 在納入此次回顧的32個試驗提供了效果,退出和副作用分析的資料. 我們在比較不同類型的抗憂鬱劑中無法發現任何在效果的不同. Tricyclic antidepressants (TCAs)比selective serotonin reuptake inhibitors (SSRIs)在不管因任何理由退出試驗的病人人數較多(RR: 1.23, CI 1.05 to 1.43)且在因副作用而退出試驗的病人人數較多(RR: 1.36, CI 1.09 to 1.70). 更進一步分析顯上與TCA相關的抗憂鬱劑在不管退出理由(RR: 1.49, CI 0.74 to 2.98)和SSRIs和因副作用退出(RR: 1.07, CI 0.43 to 2.70)有相似的退出率. 副作用的定性分析顯示在和傳統TCAs相關的腸胃和神經精神的副作用有小幅增加的現象. 我們發現SSRIs和TCAs有相同效果. 然而,我們發現一些證據顯示TCA相關的抗憂鬱症和傳統TCAs有不同的副作用且跟SSRIs比較有不同的退出率. 這個回顧認為傳統TCAs因副作用的經驗較高的退出率,雖然以上結果必須因藥物和病患族群的異質性而被小心詮釋. 本摘要由彰化基督教醫院王智仁翻譯。 此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。 這個回顧比較了以不同類型抗憂鬱劑治療老年人的憂鬱的效果,退出率和副作用.32個試驗提供了這個回顧的資料. 我們主要的發現指出tricyclic antidepressants (classical and tricyclic related)和selective serotonin reuptake inhibitors...