What are the indications for prescribing antidepressants that will lead to a clinical benefit?

BACKGROUNDThere were 36m prescriptions for an antidepressant in 2009. There is still much uncertainty about when people with depression might benefit from antidepressant medication and concern that they are prescribed when it is not really necessary. AIMS AND OBJECTIVESThe overall objective of the programme is to provide general practitioners or other clinicians with a structured assessment and clinical algorithm that will enable them to make recommendations about the likely response to selective serotonin reuptake inhibitor (SSRI) antidepressants for patients with depression in primary care. The main hypothesis is that the response to antidepressants (compared to placebo) increases with both the severity and duration of depressive symptoms Phase 1: Using previously collected data Aim1a: To carry out a systematic review and individual patient data meta-analysis to investigate the relationship between the severity of depressive symptoms and the response to antidepressantsAim 1b: We will “map” the relationship between different depression scales so we can estimate the scores on each scale corresponding to the same severity of symptoms Phase 2: Cohort study: Using both quantitative and qualitative methodsAim 2a: To estimate a clinically important difference on commonly used self-administered questionnaires for depressive symptomsAim 2b: To investigate the changes reported by patients as they recover from depressionAim 2c: To investigate any mismatch between quantitative reports of symptom change in people recovering from depressionPhase 3: Randomised controlled trial (RCT)Aim 3: To investigate the severity and duration of depressive symptoms that are associated with a clinically important response to citalopram in people with depressionRESEARCH PLANSPhase 1: Aim 1a: We will carry out a systematic review and request individual patient data (IPD) for a meta-analysis. As we expect this sample of trials to be potentially biased, we will analyse the data to simultaneously model both the aggregate data from trials and the IPD dataAim 1b: We have access to a large number of studies that will allow us to accurately “map” the scores on the different depression measures using novel statistical methodsPhase 2: Aim 2a: We will carry out a cohort study of depressed people presenting in primary care. We will ask them to rate their own improvement on a “global rating of change” scale and compare with the results of self-administered questionnaires of depression. This will allow us to calculate the difference in scores corresponding to an improvement in their “global rating of change” scaleAim 2b: On a cohort of 25 people sampled in the same way we will conduct repeated qualitative interviews along with quantitative measures to hear people’s own accounts of recovery and compare these with the results of the quantitative measures.Aim 2c: We will sample 30 people who have different responses to the “global rating of change” scale and the depression questionnaires. This will allow us to investigate, using qualitative methods, the reasons for this discrepancy. Phase 3: Aim 3: We will carry out a randomised controlled trial in which we will examine the hypothesis that the severity and duration of depressive symptoms is related to antidepressant response. We will provide an algorithm based upon a self-administered computerised assessment that can be used in primary care to provide guidance on when someone might benefit from an antidepressantRESEARCH TEAMWe have a very experience team of psychiatrists, general practitioners, service users and methodologists in statistics, epidemiology, health economics and social science. The team has worked together before and has carried out relevant researchPROGRAMME MANAGEMENTThe programme will be led by Glyn Lewis from Bristol with Chris Dowrick, Liverpool and Simon Gilbody, York being responsible for their centresRESEARCH ENVIRONMENTWe have an excellent environment in all the centres. The RCT will have the