Volume 187 - Issue 3
Beyond the evidence: is there a place for antidepressant combinations in the pharmacotherapy of depression?
Author: David P Horgan
Med J Aust 2007; 187 (3): 198-200. || doi: 10.5694/j.1326-5377.2007.tb01192.x
Published online: 6 August 2007
Published online: 6 August 2007
To the Editor: In an ironic clinician–academic dichotomy, in the same month that the Royal Australian and New Zealand College of Psychiatrists published a survey showing that 79% of Australian psychiatrists combine antidepressants and 75% of psychiatrists believe that general practitioners should be given information on this topic,1 Keks et al chose a non-psychiatric journal to “mandate that combinations be used as a last resort, and only in specialist settings”.2
Specialists have voted with their prescription pads. That a large majority of Australian psychiatrists feel ethically and clinically obliged to use combination antidepressants speaks volumes about the poor results from the suggestions outlined by Keks et al. The multiple clinical reports and reviews of the benefits of combination antidepressants,3 the suffering and death from depression, and the very low rate of complications reported to the Adverse Drug Reactions Advisory Committee from combination antidepressants do not allow the luxury of awaiting combination therapy research which may never happen. Many combinations of antihypertensives or anti-asthma medications similarly lack such rigorous proof, but are widely used. Isolated case reports of medication complications must be seen as such.
Access to psychiatrists for combination antidepressant therapy is a well intentioned but currently impractical suggestion. Most psychiatrists have massive waiting lists, and research confirms treatment resistance and progressive cell death in the hippocampus of depressed patients while awaiting effective treatment.
Australian GPs are just as capable of using combination antidepressant therapy as their international colleagues, if given the same simple information and training. Canadian GPs read in their journals advice about using combination antidepressants. Anecdotally, many Australian GPs combine antidepressants, but express the wish that the issue could be discussed openly, without them feeling intimidated. Even textbooks of psychiatry, drafted some years ago, teach about combination antidepressants. In the United States, the National Institute of Mental Health STAR*D study of 4000 patients approved combination antidepressants such as venlafaxine with mirtazapine years ago, with no safety concerns.4 Keks et al refer to treatments that today are unacceptable to many, ranging from electroconvulsive therapy to tricyclic antidepressants, despite GPs and psychiatry trainees having been warned for years by academics that tricyclics are outdated, “dirty” and dangerous.
Informed consent requires that patients be informed of all therapies that are relevant to their care and survival, and 88% of psychiatrists believe patients should be informed of combination antidepressants.1 Recent results from the STAR*D study demonstrate the superiority of modern combination antidepressants, with no statistically based evidence that they should not be used.5
References
- Horgan D, Dodd S, Berk M. A survey of combination antidepressant use in Australia. Australas Psychiatry 2007; 15: 26-29.
- Keks NA, Burrows GB, Copolov DL, et al. Beyond the evidence: is there a place for antidepressant combinations in the pharmacotherapy of depression? Med J Aust 2007; 186: 142-144. 0_CBBFFBID
- Dodd S, Horgan D, Mahli G, Berk M. To combine or not to combine? A literature review of antidepressant combination therapy. J Affect Dis 2005; 89: 1-11. 0_i1091824
- Fava M, Rush AJ, Trivedi MH, et al. Background and rationale for the sequenced treatment alternatives to relieve depression (STAR*D) study. Psychiatr Clin North Am 2003; 26: 457-494. 0_i1091828
- McGrath PJ, Stewart JW, Fava M, et al. Tranylcypromine versus venlafaxine plus mirtazapine following three failed antidepressant medication trials for depression: a STAR*D report. Am J Psychiatry 2006; 163: 1531-1541. 0_CBBJAJBH