Thursday, November 16, 2006

Lexapro For Life?

Here’s a summary from a study which appears in the Journal of Clinical Psychiatry in November (courtesy of PsychCentral).

“Between 2000 and 2003, researchers evaluated approximately 200 participants at 28 centers in the United States who had responded positively to eight weeks of treatment with one of four different SSRIs: fluoxetine, sertraline, paroxetine or citalopram. This was followed by four months of treatment with escitalopram. These participants were then randomly assigned to fixed-dose treatment with 10 or 20 mg of escitalopram or placebo for one year.

“Patients who were switched to placebo showed a significantly higher rate of depression recurrence (65 percent), compared to those who stayed on escitalopram (27 percent),” said Kornstein. “This was true even though the patients showed a full resolution of their depression at the start of maintenance treatment.” The medication was found to be safe and well tolerated throughout the study, she said.

These findings indicate the importance of maintenance therapy for patients with recurrent major depressive disorder beyond four to six months of improvement, even if a patient’s depressive symptoms appear to be resolved,” she said.

This work was funded by Forest Research Institute.”

Your first impression may be: Lexapro (escitalopram) for life! Let’s look at the flip side of the coin, shall we?

First, discontinuing medication for one group and putting them on placebo is going to set up an increased rate of depression due to discontinuation/withdrawal from the medication.

Second, and more importantly, a meta-analysis by De Maat, Dekker, Schoevers, & de Jonghe regarding long-term treatment outcomes for psychotherapy and medication found that the longer term relapse rate for medication was 57% compared to 24% for psychotherapy. In the studies they examined, both medication and psychotherapy were provided in the short-term, then discontinued, and the long-term results were then analyzed.

I suppose it may be true that if you continue people on medication for a longer time, they may maintain lower symptom levels. But, when the medication is taken away, look what happens – likely, it’s relapse.

So is it cost-effective to keep people on so-called maintenance medication therapy indefinitely as compared to providing psychotherapy, which provides superior long-term results without the need for maintenance treatment? I think the answer is an obvious no.

In addition, there is precious little evidence regarding the long-term effects of antidepressants, as can be seen in an interesting article here. Despite the widespread long-term use of antidepressants, surprisingly little is known about their impact and what happens upon discontinuation of long-term treatment.

To summarize: We know antidepressants fare much worse than psychotherapy when both treatments are provided short-term then discontinued and outcomes are examined over the long-term. We don’t know the long-term effects of keeping people on indefinite maintenance pharmacotherapy. I have a feeling some people will make a big deal about Kornstein’s findings; please refer them to this post.

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