JC2011-12 Star D - Dr

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Presented by Nick Nelson (for Little Timmy Blue-Eyes)

Study Design :

Study Design Level 1: Observational study of citalopram Level 2: Randomized to switch, (bupropion, venlafaxine or sertraline, or CBT) augment, (buspirone, bupropion, or CBT). Level 3: Switch (mirtazapine and nortriptyline) or agument (Li or T3) Level 4: Switch (tranylcypromine or mirtazapine)

Study Design :

Study Design Level 1: Observational study of citalopram Level 2: Randomized to switch, (bupropion, venlafaxine or sertraline, or CBT) augment, (buspirone, bupropion, or CBT). Level 3: Switch (mirtazapine and nortriptyline) or agument (Li or T3) Level 4: Switch (tranylcypromine or mirtazapine)

PowerPoint Presentation:

bupropion-SR Mechanism: Active metabolites inhibit re-uptake of norepinephrine and dopamine.

PowerPoint Presentation:

venlafaxine-ER Mechanism: Inhibits re-uptake of serotonin and norepinephrine.

PowerPoint Presentation:

sertraline Mechanism: Inhibits re-uptake of serotonin.

Results: Probability of Remission Over Tme:

Results: Probability of Remission Over Tme

Results: Remission Rates at 14 weeks:

Results: Remission Rates at 14 weeks bupropion-SR venlafaxine-ER sertraline 21.3% 17.6% 24.8% No statistically significant difference between the three groups was observed.

Discussion Questions:

Discussion Questions What are some methodological problems with this trial? What do these results mean about antidepressants in primary care?

Discussion: Methodologic Problems:

“Without a placebo group, we cannot be certain that any of these treatments was specifically effective, (i.e., the results were due to the pharmacologic effects of the medication” Discussion: Methodologic Problems

Discussion: Methodologic Problems:

? “Without a placebo group, we cannot be certain that any of these treatments was specifically effective, (i.e., the results were due to the pharmacologic effects of the medication” Discussion: Methodologic Problems

Discussion: Methodologic Problems:

? ? “Without a placebo group, we cannot be certain that any of these treatments was specifically effective, (i.e., the results were due to the pharmacologic effects of the medication” Discussion: Methodologic Problems

Discussion: Methodologic Problems:

? ? ? “Without a placebo group, we cannot be certain that any of these treatments was specifically effective, (i.e., the results were due to the pharmacologic effects of the medication” Discussion: Methodologic Problems

Discussion: Methodologic Problems:

Discussion: Methodologic Problems “On the other hand, switching to a placebo after an initial failed treatment would have aroused concerns about ethics…”

Discussion: Primary Care Implications:

Discussion: Primary Care Implications Among patients who cannot tolerate or who do not have a remission in response to an initial SSRI, approximately one in four patients had a remission on switching to sustained-release bupropion, sertraline, or extended release venlafaxine; these three drugs had simlar efficacy and tolerability. These findings highlight the need for more broadly effective antidepressant treatments.

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