Antidepressant drug effects and depression severity: a patient-level meta-analysis.
BACKGROUND
Antidepressant medications represent the best established treatment for major depressive disorder, but there is little evidence that they have a specific pharmacological effect relative to pill placebo for patients with less severe depression.


OBJECTIVE
To estimate the relative benefit of medication vs placebo across a wide range of initial symptom severity in patients diagnosed with depression.


METHODS
PubMed, PsycINFO, and the Cochrane Library databases were searched from January 1980 through March 2009, along with references from meta-analyses and reviews.


METHODS
Randomized placebo-controlled trials of antidepressants approved by the Food and Drug Administration in the treatment of major or minor depressive disorder were selected. Studies were included if their authors provided the requisite original data, they comprised adult outpatients, they included a medication vs placebo comparison for at least 6 weeks, they did not exclude patients on the basis of a placebo washout period, and they used the Hamilton Depression Rating Scale (HDRS). Data from 6 studies (718 patients) were included.


METHODS
Individual patient-level data were obtained from study authors.


RESULTS
Medication vs placebo differences varied substantially as a function of baseline severity. Among patients with HDRS scores below 23, Cohen d effect sizes for the difference between medication and placebo were estimated to be less than 0.20 (a standard definition of a small effect). Estimates of the magnitude of the superiority of medication over placebo increased with increases in baseline depression severity and crossed the threshold defined by the National Institute for Clinical Excellence for a clinically significant difference at a baseline HDRS score of 25.


CONCLUSIONS
The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.
Fournier
Jay C
JC
Department of Psychology, University of Pennsylvania, 3720 Walnut St, Philadelphia, PA 19104, USA. jcf@sas.upenn.edu
DeRubeis
Robert J
RJ
Hollon
Steven D
SD
Dimidjian
Sona
S
Amsterdam
Jay D
JD
Shelton
Richard C
RC
Fawcett
Jan
J
D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use*; D003863:Depression / Q000188:drug therapy*; D003865:Major Depressive Disorder / Q000188:drug therapy*; D006801:Humans; D015990:Placebo Effect; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
D000928:Antidepressive Agents