April 20, 2022

expert reaction to study looking at antidepressants and health-related quality of life

A study published in PLOS ONE looks at antidepressants and health-related quality of life (HRQoL) for patients with depression.

Dr Livia de Picker, Postdoctoral researcher, Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, said:

“The methodology used in this study is unable to tell us whether antidepressants are suitable for use in the long term. This is due to the time frames used being inappropriate to address the question of ‘long term use’ in a condition that is often episodic in nature, and also that the paper cannot account for major differences between the two groups which could also explain these results.

“What these data do point towards is the persistent treatment gap for depression in the US, with only 57.6% of patients with MDD receiving treatment with antidepressants over a 2 year follow-up.”

Dr Gemma Lewis, Sir Henry Dale Fellow, UCL Division of Psychiatry, UCL, said:

“In this study, the people who received antidepressants had worse quality of life, and are likely to have been more severely depressed, than those who did not. This type of bias is difficult to eliminate in a naturalistic study like this, which does not involve an experimental design. Clinical trials with experimental designs have found that antidepressants improve mental health related quality of life.

“The date that people began their antidepressants is also relevant. When this study began, many people are likely to have been receiving their antidepressants for several years. When people started their antidepressants, they may have had worse quality of life, and been more severely depressed, than they were by the time the study started. In the ANTLER trial, we found that remaining on long-term antidepressants reduced the risk of relapse, and helped maintain quality of life, although many people could also safely discontinue.”

Dr Michael Bloomfield, Excellence Fellow, Head of Translational Psychiatry Research Group and Consultant Psychiatrist, UCL, said:

“This press release does not accurately reflect the evidence base on antidepressants and the research findings they describe here are not robust. This study does not adequately address whether antidepressant use is associated long-term quality of life. There are a few factors in the design of the study that contribute to this including not accounting for the severity of depressive symptoms.

“We have known for a very long time that being depressed or suffering from other types of mental health problem is understandably associated with impaired quality of life. Anyone who is concerned about taking or starting a medicine used in the treatment of depression should speak with their doctor.”

Prof Eduard Vieta, Professor of Psychiatry and Chair, University of Barcelona, said:

“The major limitation of this paper is that, as is often the case with these kinds of studies, the confounder by indication. The inability to control for severity of depression between the two different groups is a crucial flaw and therefore there is little we can learn from this data.”

Dr Andreas Reif, Head of Department of Psychiatry, University Hospital Frankfurt, Goethe University, said:

“The timeframe which is used is not appropriate. In 90% of cases depression is an episodic disorder, meaning that it usually remits within around 9 months.”

Prof David Curtis, Honorary Professor, UCL Genetics Institute, said:

“This study does not tell us anything about the effect of taking antidepressants on a patient’s quality of life. It simply compares people who were and were not taking antidepressants. One might well assume that the people who were taking antidepressants had been more severely depressed than those who were not. From this point of view, one could argue that it seems that the antidepressants were effective and that with their use people who had presented with more severe depression did not have markedly reduced quality of life. However the reality is that this kind of observational study tells us nothing about causation. For that, clinical trials are required and numerous such trials have demonstrated that, on average, antidepressants are effective in terms of treating depressive illness and in improving the quality of life of patients with significant depression.”

Dr Rebecca Sheriff, Consultant Psychiatrist and Senior Clinical Research Fellow, University of Oxford, said:

“The title of the press release suggests this is looking at long-term data but to me long-term would imply over 5-10 years, and this study was over two years. Also, it measured health related quality of life, rather than physical and mental health as such (as implied in the abstract). Overall, this paper is accurate but with typos and incorrect grammar, for example the use of ‘depression disorder’.

“The data is strong but not rich. There are large numbers of people analysed which adds to the strength of the statistical analysis. However, we are looking at lots of numbers rather than rich data. Essentially depressive disorder is a relapsing/remitting condition (it gets better and worse over time). It is not surprising therefore that quality of life improved in both groups. We are missing a lot of potentially helpful information such as what the people not taking antidepressants might have been doing, in terms of self-help strategies or non-pharmacological treatments. In particular it is worth noting that being female and white ethnicity was associated with antidepressant use. In addition, large proportions of those surveyed were married, had higher incomes and were privately insured. This reduces the generalisability of the findings and demonstrates the extremely uncomfortable finding that large proportions of people are underrepresented in health services and health research (particularly ethnic minorities).

“The paper discusses comparisons between antidepressants and talking therapy (psychotherapy) and the potential of using this in combination. However, one would think interventions with the biggest impacts on health-related quality of life might be community activities, such as engagement with sports clubs or arts and culture. This is an under-researched area. I agree with the authors that academia has become too focussed on measuring depressive symptoms themselves over the short term, rather than outcomes that are important to service-users such as quality of life.”

Prof Michael Sharpe, Professor of Psychological Medicine, University of Oxford, said:

“This study is an analysis of routine date from the USA to study the quality of life of people with depression. In the first analysis the authors determined how quality of life changed for people taking antidepressant drugs and found some aspects to be improved. In a second analysis they compared this improvement with that seen in depressed people who had not taken antidepressants and found no difference from those who had.

“Whilst this study reports evidence that taking antidepressants may improve quality of life of people with depression, as the authors themselves admit, there are too many unknowns, particularly in the second analysis to draw clear conclusions. For example, we don’t know if those taking antidepressants were similar to those who were not, in terms of type and severity of depression and what other treatments were received.

“The study does serve to remind researchers of the importance of measuring the long-term outcomes of treatments for depression. However, this study has no clear implication for the care of patients with depression and certainly should not discourage patients who may benefit from taking these drugs.”

‘Antidepressants and health-related quality of life (HRQoL) for patients with depression: Analysis of the medical expenditure panel survey from the United States’ by Omar A. Almohammed et al. was published in PLOS ONE at 19:00 UK time on Wednesday 20^th April.

DOI: https://doi.org/10.1371/journal.pone.0265928

Declared interests

Dr Livia de Picker: “I have no conflicts of interest to declare in relation to the current work. Outside this work:

– Performed paid consultancy for Boehringer-Ingelheim

– Received research grants for Boehringer-Ingelheim and Janssen R&D”

Dr Gemma Lewis: “No conflicts of interest. Dr Gemma Lewis is an author on the ANTLER and PANDA trials.”

Dr Michael Bloomfield: “No conflicts of interest.”

Prof Eduard Vieta: “I have participated through my institution in Clinical trials of antidepressants and advisory boards of the following companies: Angelini, Biogen, Janssen, and Lundbeck.”

Dr Andreas Reif: “I am serving on several ad boards / speakers bureaus (Janssen, SAGE/Biogen, Boehringer, cyclerion, Medice, Shire/Takeda), but none of these are for conventional antidepressants. Also I am involved in the German depression guidelines, and sit on executive committees of the German Psych Assoc (DGPPN) and ECNP.”

Prof David Curtis: “I have no conflict of interest to declare.”

Prof Michael Sharpe: “No conflicts.”

No others received