Fluoxetine versus other types of pharmacotherapy for depression
- PMID: 24353997
- PMCID: PMC11513554
- DOI: 10.1002/14651858.CD004185.pub3
Fluoxetine versus other types of pharmacotherapy for depression
Abstract
Background: Depression is common in primary care and is associated with marked personal, social and economic morbidity, thus creating significant demands on service providers. The antidepressant fluoxetine has been studied in many randomised controlled trials (RCTs) in comparison with other conventional and unconventional antidepressants. However, these studies have produced conflicting findings.Other systematic reviews have considered selective serotonin reuptake inhibitor (SSRIs) as a group which limits the applicability of the indings for fluoxetine alone. Therefore, this review intends to provide specific and clinically useful information regarding the effects of fluoxetine for depression compared with tricyclics (TCAs), SSRIs, serotonin-noradrenaline reuptake inhibitors (SNRIs), monoamineoxidase inhibitors (MAOIs) and newer agents, and other conventional and unconventional agents.
Objectives: To assess the effects of fluoxetine in comparison with all other antidepressive agents for depression in adult individuals with unipolar major depressive disorder.
Search methods: We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group Controlled Trials Register (CCDANCTR)to 11May 2012. This register includes relevant RCTs from the Cochrane Central Register of Controlled Trials (CENTRAL) (all years),MEDLINE (1950 to date), EMBASE (1974 to date) and PsycINFO (1967 to date). No language restriction was applied. Reference lists of relevant papers and previous systematic reviews were handsearched. The pharmaceutical company marketing fluoxetine and experts in this field were contacted for supplemental data.
Selection criteria: All RCTs comparing fluoxetine with any other AD (including non-conventional agents such as hypericum) for patients with unipolar major depressive disorder (regardless of the diagnostic criteria used) were included. For trials that had a cross-over design only results from the first randomisation period were considered.
Data collection and analysis: Data were independently extracted by two review authors using a standard form. Responders to treatment were calculated on an intention-to-treat basis: dropouts were always included in this analysis. When data on dropouts were carried forward and included in the efficacy evaluation, they were analysed according to the primary studies; when dropouts were excluded from any assessment in the primary studies, they were considered as treatment failures. Scores from continuous outcomes were analysed by including patients with a final assessment or with the last observation carried forward. Tolerability data were analysed by calculating the proportion of patients who failed to complete the study due to any causes and due to side effects or inefficacy. For dichotomous data, odds ratios (ORs) were calculated with 95% confidence intervals (CI) using the random-effects model. Continuous data were analysed using standardised mean differences (SMD) with 95% CI.
Main results: A total of 171 studies were included in the analysis (24,868 participants). The included studies were undertaken between 1984 and 2012. Studies had homogenous characteristics in terms of design, intervention and outcome measures. The assessment of quality with the risk of bias tool revealed that the great majority of them failed to report methodological details, like the method of random sequence generation, the allocation concealment and blinding. Moreover, most of the included studies were sponsored by drug companies, so the potential for overestimation of treatment effect due to sponsorship bias should be considered in interpreting the results. Fluoxetine was as effective as the TCAs when considered as a group both on a dichotomous outcome (reduction of at least 50% on the Hamilton Depression Scale) (OR 0.97, 95% CI 0.77 to 1.22, 24 RCTs, 2124 participants) and a continuous outcome (mean scores at the end of the trial or change score on depression measures) (SMD 0.03, 95% CI -0.07 to 0.14, 50 RCTs, 3393 participants). On a dichotomousoutcome, fluoxetine was less effective than dothiepin or dosulepin (OR 2.13, 95% CI 1.08 to 4.20; number needed to treat (NNT) =6, 95% CI 3 to 50, 2 RCTs, 144 participants), sertraline (OR 1.37, 95% CI 1.08 to 1.74; NNT = 13, 95% CI 7 to 58, 6 RCTs, 1188 participants), mirtazapine (OR 1.46, 95% CI 1.04 to 2.04; NNT = 12, 95% CI 6 to 134, 4 RCTs, 600 participants) and venlafaxine(OR 1.29, 95% CI 1.10 to 1.51; NNT = 11, 95% CI 8 to 16, 12 RCTs, 3387 participants). On a continuous outcome, fluoxetine was more effective than ABT-200 (SMD -1.85, 95% CI -2.25 to -1.45, 1 RCT, 141 participants) and milnacipran (SMD -0.36, 95% CI-0.63 to -0.08, 2 RCTs, 213 participants); conversely, it was less effective than venlafaxine (SMD 0.10, 95% CI 0 to 0.19, 13 RCTs,3097 participants). Fluoxetine was better tolerated than TCAs considered as a group (total dropout OR 0.79, 95% CI 0.65 to 0.96;NNT = 20, 95% CI 13 to 48, 49 RCTs, 4194 participants) and was better tolerated in comparison with individual ADs, in particular amitriptyline (total dropout OR 0.62, 95% CI 0.46 to 0.85; NNT = 13, 95% CI 8 to 39, 18 RCTs, 1089 participants), and among the newer ADs ABT-200 (total dropout OR 0.18, 95% CI 0.08 to 0.39; NNT = 3, 95% CI 2 to 5, 1 RCT, 144 participants), pramipexole(total dropout OR 0.12, 95% CI 0.03 to 0.42, NNT = 3, 95% CI 2 to 5, 1 RCT, 105 participants), and reboxetine (total dropout OR0.60, 95% CI 0.44 to 0.82, NNT = 9, 95% CI 6 to 24, 4 RCTs, 764 participants).
Authors' conclusions: The present study detected differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain.Moreover, the assessment of quality with the risk of bias tool showed that the great majority of included studies failed to report details on methodological procedures. Of consequence, no definitive implications can be drawn from the studies' results. The better efficacy profile of sertraline and venlafaxine (and possibly other ADs) over fluoxetine may be clinically meaningful,as already suggested by other systematic reviews. In addition to efficacy data, treatment decisions should also be based on considerations of drug toxicity, patient acceptability and cost.
Conflict of interest statement
LRM, CG, MP, DP, AC, CB: none declared. TAF has received honoraria for speaking at continuing medical education (CME) meetings sponsored by Asahi Kasei, Eli Lilly, GlaxoSmithKline, Mochida, MSD, Otsuka, Pfizer, Shionogi and Tanabe‐Mitsubishi. He is a diplomate of the Academy of Cognitive Therapy. He has received royalties from Igaku‐Shoin, Seiwa‐Shoten and Nihon Bunka Kagakusha. He is on the advisory board for Sekisui Chemicals and Takeda Science Foundation. The Japanese Ministry of Education, Science, and Technology; the Japanese Ministry of Health, Labor and Welfare; and the Japan Foundation for Neuroscience and Mental Health have funded his research projects.
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Update of
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Fluoxetine versus other types of pharmacotherapy for depression.Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004185. doi: 10.1002/14651858.CD004185.pub2. Cochrane Database Syst Rev. 2005. Update in: Cochrane Database Syst Rev. 2013 Jul 17;(7):CD004185. doi: 10.1002/14651858.CD004185.pub3. PMID: 16235353 Free PMC article. Updated.
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- Dalery J. Fluvoxamine and fluoxetine in the treatment of depression; similarities and differences. XIth European College of Neuropsychopharmacology Congress, Paris, France. 1998.
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Demyttenaere 2004 {published data only}
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Wehmeier 2005 {published data only}
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WELL AK1A4006 {unpublished data only}
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- GlaxoSmithKline. A multicenter, double blind, placebo‐controlled comparison of the safety and efficacy and effects on sexual functioning of Wellbutrin (bupropion HCI) Sustained Release (SR) and Fluoxetine in outpatients with moderate to severe recurrent Major Depression. GSK ‐ Clinical Study Register (www.gsk‐clinicalstudyregister.com).
Wheatley 1998 {published data only}
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- Kremer CM. Mirtazapine versus fluoxetine ‐ efficacy on symptoms associated with depression. 151st Annual Meeting of the American Psychiatric Association, Toronto, Ontario, Canada. 1998.
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- Kremer CM. Mirtazapine vs fluoxetine: Efficacy on symptoms associated with depression. XXIst Collegium Internationale Neuro‐Psychopharmacologicum, Glasgow, Scotland. 1998.
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- Wheatley D, Kremer CM. A randomized, double‐blind comparison of mirtazapine and fluoxetine in patients with major depression. 150th Annual Meeting of the American Psychiatric Association, San Diego, CA. 1997.
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Williams 1993 {published data only}
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Winokur 2003 {published data only}
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- Winokur A, DeMartinis NA 3rd, McNally DP, Gary EM, Cormier JL, Gary KA. Comparative effects of mirtazapine and fluoxetine on sleep physiology measures in patients with major depression and insomnia. Journal of Clinical Psychiatry 2003;64(10):1224‐9. - PubMed
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Wolf 2001 {published data only}
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- Gattaz WF, Maras Schmidt AA, Löw Bahro HM, Kohnen Dittmann RW, Wolff Berger RM, Riemann D. Efficacy and safety of fluoxetine versus trimipramine in geriatric depression. Xth World Congress of Psychiatry, Madrid, Spain. 1996.
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Young 1987 {published data only}
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Yu 1997 {published data only}
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Zhao 2006 a {published data only}
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References to studies excluded from this review
Baca Baldomero 2005 {published data only}
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Bitrain 2011 {published data only}
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Cohn 1989 {published data only}
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Ducher 2008 {published data only}
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Goodnick 1987 {published data only}
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Gu 2001 {published data only}
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Hunter 2006 {published data only}
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Iovieno 2011 {published data only}
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Kroenke 2001 {published data only}
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Musgnung 2005 {published data only}
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Nemetz 2005 {published data only}
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Peveler 2005 {published data only}
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References to studies awaiting assessment
Chen 2006 {published data only}
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Huang 2006a {published data only}
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Huang 2006b {published data only}
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Li 2006a {published data only}
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Li 2006b {published data only}
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Li 2006c {published data only}
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Liang 2005 {published data only}
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Licinio 2004 {published data only}
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Ma 2007 {published data only}
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- Kolden G. Brain Imaging Techniques That Predict Antidepressant Responsiveness. www.clinicaltrials.gov/ct2/show/NCT00909155.
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Qin 2006 {published data only}
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Sackeim 2006 {published data only}
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Shen 2005 {published data only}
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Sun 2005 {published data only}
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Sun 2006 {published data only}
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Tan 1997 {published data only}
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Wang 2006 {published data only}
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Wang 2007a {published data only}
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Wang 2007b {published data only}
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Wang 2009 {published data only}
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Wang 2011 {published data only}
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Xiao 2005 {published data only}
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- Xiao B, Xie W, Shi Z. A clinical control study of venlafaxine and fluoxetine in the treatment of senile depression. Chinese Journal of Behavioral Medical Science 2005;14:703‐4.
Xu 2010 {published data only}
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- Xu S‐Q, Cao J, Huang W‐W. Comparison of escitalopram with fluoxetine in old depressive patients. Chinese Journal of New Drugs 2010;19:207‐9.
Zhao 2005 {published data only}
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- Zhao HD, Wang JL, Xia JM. A comparative study of citalopram and fluoxetine in the treatment of senile depressive disorders. Chinese Mental Health Journal 2005;19:355‐6.
Zhao 2006 {published data only}
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- Zhao H, Guan T. A control study in the treatment of depressive disorder with citalopram and fluoxetine. Evaluation and Analysis of Drug‐Use in Hospitals of China 2006;6:106‐8.
Zhou 2005 {published data only}
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- Zhou M, Yao L. The efficacy and tolerability of venlafaxine and fluoxetine in treatment of elderly patients with first‐episode depression. Chinese Journal of Psychiatry 2005;38:157‐60.
Zhu 2005 {published data only}
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- Zhu J, Jiang X, Zhou D, Zhang F. Comparative study of mirtazapine vs. fluoxetine in treatment of elderly depressive patients. Journal of Clinical Psychological Medicine 2005;15:277‐8.
Zhu 2006 {published data only}
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- Zhu J. Comparative study of mirtazapine and fluoxetine in the treatment of senile depression. China Journal of Health Psychology 2006;14:546‐7.
References to ongoing studies
ChiCTR‐TRC‐11001668 {unpublished data only}
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CTRI/2011/05/001719 {unpublished data only}
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EUCTR2007‐002130‐11‐ES {unpublished data only}
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NCT01204086 {unpublished data only}
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NCT01254305 {unpublished data only}
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