Magazine article Clinical Psychiatry News

Benzodiazepines for Major Depression

Magazine article Clinical Psychiatry News

Benzodiazepines for Major Depression

Article excerpt

The Problem

You have a patient with major depression. Symptoms include anxiety and insomnia. You prescribe an antidepressant and consider immediate augmentation with a benzodiazepine, but you are worried about the possibility that benzodiazepines could worsen the depression.

The Question

Do benzodiazepines aid antidepressants in treating major depression?

The Analysis

We went to www.cochrane. org/and located a comprehensive review of this topic (Cochrane Database of Syst. Rev. 2001;CD0010 26. [doi: 0.1002/14651858]).

Then we performed a Medline search to update the Cochrane Review by combining "antide-pressant, benzodiazepine, and depressive disorder."

The Evidence

The Cochrane reviewers searched 1,475 articles, which ultimately yielded 25 studies. Of those 25 studies, 10 were considered to be of adequate quality to be included in the review. Study participants had to be 18 years of age or older and diagnosed with major depressive disorder. The studies had to compare any antidepressant combined with a benzodiazepine vs. an antidepressant alone for a minimum of 4 weeks.

Antidepressant dosing had to be 100 mg daily of imipramine equivalents or higher (eight studies used tricyclic antidepressants and two used fluoxetine). Studies also had to be double blinded and randomized. The Cochrane reviewers graded study quality in part based upon clarity of double blinding.

The Cochrane analysis examined the results of 731 patients. For most, their depression was rated using the Hamilton Rating Scale for Depression (HAM-D). Response in depression was defined as a 50% or greater reduction in HAM-D score from baseline. For various statistical reasons, the Cochrane reviewers used relative risk (RR) as a measure of the likelihood of achieving a HAM-D reduction of 50% or more.

For the group that received antidepressant monotherapy, RR was 1.57 at week 1, 1.23 at week 2, 1.13 at week 4 (no longer considered statistically significant), 1.04 at weeks 6-8, and 1.05 at week 12.

For the combination antidepressant-benzo-diazepine group, RR was 1.62 at week 1, 1.37 at week 2, 1.18 at week 4, and 0.95 at weeks 6-8. When the reviewers used only the two highest quality combination studies, the differences were even greater: RR of 2.45 at week 1, 1.58 at week 2, and 1.40 at week 4.

One analysis compared the effects of short-and long-acting benzodiazepines. Two studies using short-acting benzodiazepines were pooled and compared with seven studies using longer-acting benzodiazepines: In the short-acting group, RR was 1.65 at week 1, 1. …

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