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A recent meta-analysis by Cipriani and colleagues provides as good and balanced a synopsis as we will likely ever have of the results from the 522 trials of 21 antidepressants in 116477 participants. 1 The findings have been widely reported, with differing interpretations, including some uncritical acceptance of the benefits of antidepressants. 2 More objectively, how should these findings inform practice?
Cipriani and colleagues are admirably clear about the limitations of included studies. They rated 82% as having moderate to high risk of bias. They also noted specific biases such as a novelty effect, whereby a medication looked significantly better when evaluated as the novel comparator in a trial than when as the older or control comparator. In addition, 78% of studies were funded by drug companies, and many other studies failed to report funding at all. It is somewhat reassuring that the authors report "funding by industry was not associated with substantial differences in terms of response or dropout rates."
Finally, it is important to note the patient population in this meta-analysis was limited to adults with moderate to severe depression and an average Hamilton depression score of 26. 3
The primary endpoint was the number of patients who achieved a 50% change in Hamilton depression score at 8 weeks. Remission rates at 8 weeks were also reported. The authors used "all-cause discontinuation" as a measure of acceptability since this endpoint combines both efficacy and tolerability. They also looked at drop-outs due to adverse events but didn't report data on specific adverse effects such as sedation, dry mouth, sexual dysfunction, and weight gain-vital information for patients choosing between therapeutic options.
All antidepressants in this meta-analysis "worked," as they all significantly increased the...