Comparative Efficacy and Acceptability of Antidepressants in Parkinson's Disease: A Network Meta-Analysis

Abstract

BackgroundDepression is a common non-motor symptom in patients with Parkinson's disease (PD). There are many kinds of antidepressants being used, such as tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and Dopamine agonists which are suggested as alternative antidepressants for the treatment of depression in PD. Which one should we choose first? Literatures have shown inconsistent results.MethodsWe conducted a network meta-analysis of randomized controlled trials to compare the efficacy and acceptability of therapeutic methods for the treatment of depression in Parkinson's disease.ResultsWe used the odds ratios (OR) as effect size firstly and the results indicated no statistical significance between each compared intervention. Then we used the logarithm of the individual odds ratios as effect size. With efficacy of TCAs as the standard of comparison, the degree of incoherence (a measure of how closely the entire network fits together) was small (ω = 4.824827e-05). The logor were: SSRIs −0.69 (95% CI −1.28– −0.10); Pramipexole −0.73 (−1.71– −0.26); Pergolide −1.97 (−3.67– 0.27); SNRIs −0.86 (−1.86– 0.15); Placebo −1.24 (−1.99– −0.50). With Placebo as the standard of comparison, the logor were: TCAs 1.24 (0.50– 1.99); SSRIs 0.55 (−0.03– 1.13); Pramipexole 0.51 (−0.12– 1.15); Pergolide −0.73 (−2.25– 0.80); SNRIs 0.38 (−0.42– 1.19); TCAs, pramipexole, pergolide and SNRIs showed better profile of acceptability, leading to significant fewer discontinuations than that of SSRIs.ConclusionsThere is insufficient evidence to support antidepressant efficacy for SSRIs, pramipexole, pergolide and SNRIs. TCAs might be the best choice when starting antidepressant treatment in patients of Parkinson's disease because it has the most favorable balance between benefits and acceptability, followed by pramipexole and SNRIs, SSRIs might be the last choice.

Using Canadian Primary Care Sentinel Surveillance Network data to examine depression in patients with a diagnosis of Parkinson disease: a retrospective cohort study

“…Previous evidence suggests that SSRIs, such as paroxetine, may magnify the motor symptoms in Parkinson disease. 33,34 More recent meta-analyses 35,36 and the Canadian guidelines 12 suggest that tricyclics might be more effective for this population. Discrepancies found between commonly prescribed SSRIs for depression and what is recommended by the Canadian guidelines 12 might be the result of different factors, , p value = probability value, RR = rate ratio.…”

“…12,35,36 Increased practice support and resources could promote routine and comprehensive assessment of comorbidities and medications in this population. Clinicians are required to deliver individualized care but also carry out guideline-based care for multiple segments of the practice population.…”

Antidepresivos en la enfermedad de Parkinson. Recomendaciones del grupo de trastornos del movimiento de la Asociación Madrileña de Neurología

“…Atomoxetina y sertralina no fueron capaces de demostrar eficacia 11,12 . Con todo, un metaanálisis publicado en 2011 concluyó que los antidepresivos tricíclicos podrían ser los más eficaces en el tratamiento de la depresión en la EP, seguidos de los inhibidores de la recaptación de serotonina y noradrenalina (IRSN) y estando los inhibidores selectivos de la recaptación de serotonina (ISRS) en último lugar 13 9 . En este sentido, un reciente metaanálisis, que ya incluyó el mencionado estudio, concluyó que específicamente los ISRS mejoran de forma significativa la depresión en la EP, sembrando dudas sobre la eficacia de los tricíclicos 16 .…”

“…En general, los antidepresivos en la EP son bien tolerados 13,14 . No obstante, teniendo en cuenta el efecto anticolinérgico de los tricíclicos, estos deben ser utilizados con precaución en caso de pacientes con retención urinaria, glaucoma de ángulo cerrado y patología cardiovascular 14 …”

Pramipexole Extended-Release: A Review of Its Use in Patients with Parkinson’s Disease

“…Therefore, while it is not unreasonable to assume that pramipexole ER will ameliorate depressive as well as motor symptoms in patients with PD, as has been seen with the IR formulation [42,49], this remains to be formally demonstrated. The authors of a recent network meta-analysis of randomized controlled trials have concluded that there is insufficient evidence to support the efficacy of pramipexole (or that of selective serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors and pergolide) in treating depressive symptoms in patients with PD [50]. Pramipexole is, however, considered to be efficacious and, by implication, clinically useful, for treating depressive symptoms, according to current MDS guidelines [51].…”