Geddes, 2003 Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review

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Lancet. 2003 Feb 22;361(9358):653-61.

Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review.

Geddes JR¹, Carney SM, Davies C, Furukawa TA, Kupfer DJ, Frank E, Goodwin GM

 

Abstract https://www.ncbi.nlm.nih.gov/pubmed/12606176                  Fullull text https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0020316/

BACKGROUND:

Antidepressant drugs can promote remission from acute depressive episodes. Our aim was to establish how long such treatments should be continued to prevent relapse.

METHOD:

We did a systematic overview of evidence from randomised trials of continuing treatment with antidepressants in patients with depressive disorders who have responded to acute treatment. Medline, Embase, Cinahl, PsycLIT, Psyndex, and Lilacs were searched.

FINDINGS:

Data were pooled from 31 randomised trials (4410 participants). Continuing treatment with antidepressants reduced the odds of relapse by 70% (95% CI 62-78; 2p<0.00001) compared with treatment discontinuation. The average rate of relapse on placebo was 41% compared with 18% on active treatment. The treatment effect seemed to persist for up to 36 months, although most trials were of 12 months' duration, and so the evidence on longer-term treatment requires confirmation. Significantly more participants allocated antidepressants withdrew from the trials than did those allocated to placebo (18% vs 15%, respectively; odds ratio 1.30, 95% CI 1.07-1.59): the treatment effect could be even greater in adherent patients. The two-thirds reduction in risk of depressive relapse seemed to be largely independent of the underlying risk of relapse, the duration of treatment before randomisation, or the duration of the randomly allocated therapy.

INTERPRETATION:

Antidepressants reduce the risk of relapse in depressive disorder, and continued treatment with antidepressants would benefit many patients with recurrent depressive disorder. The treatment benefit for an individual patient will depend on their absolute risk of relapse with greater absolute benefits in those at higher risk. Further trials are needed to establish the optimum length of therapy and should include patients who were not well represented in these trials, including those at low risk of relapse.

 

 

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I only post this because this paper was quoted by a doctor online recently as proof of the efficacy of maintenance treatment. It only took reading the abstract to identify one obvious flaw and to raise questions, and unfortunately I can't get the whole paper.

 

This paper is a meta analysis of a bunch of trials. Overall, I think that the only thing that can be taken from the trials which form the basis of this paper is that they likely prove the existence of depressive symptoms as withdrawal effects, although of course that is not the conclusion reached.

 

Major problem: taper duration. Although the taper speed doesn't seem to be spelled out, it does say that "most trials were of 12 months' duration". It seems unlikely that the taper was the whole 12 months, and even that is most likely too short, so I think all we can take from this is that it is at least possible that these people were put into withdrawal symptoms. Perhaps the main surprise is that at only 41% relapsed after this treatment, though there is no way to know what happened to these people after.

 

The questions raised... "significantly more participants allocated antidepressants withdrew from the trials than did those allocated to placebo" - suggesting, what, that they were randomized to a new drug and it was awful and they wanted to get back to their normal drug again? Hard to tell what that means without seeing the whole paper.