Should escitalopram be used in depression? (Escitalopram versus placebo)

Quality assessmentSummary of findingsImportance
No. of patientsEffectQuality
No. of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther considerationsEscitalopramPlaceboRelative (95% CI)Absolute
Non-response - ordered by baseline severity
11randomised trialsno serious limitationsserious1no serious indirectnessno serious imprecisionnone936/1881 (49.8%)971/1614 (60.2%)RR 0.81 (0.75 to 0.88)114 fewer per 1000 (from 72 fewer to 150 fewer)⊕⊕⊕○
MODERATE
CRITICAL
58.5%111 fewer per 1000 (from 70 fewer to 146 fewer)
Non-response - Escitalopram 10mg
4randomised trialsno serious limitationsserious2no serious indirectnessno serious imprecisionnone407/758 (53.7%)388/628 (61.8%)RR 0.84 (0.72 to 0.98)99 fewer per 1000 (from 12 fewer to 173 fewer)⊕⊕⊕○
MODERATE
CRITICAL
63.4%101 fewer per 1000 (from 13 fewer to 178 fewer)
Non-response - Escitalopram 20mg
1randomised trialsno serious limitationsserious3no serious indirectnessno serious imprecisionnone62/125 (49.6%)89/122 (73%)RR 0.68 (0.55 to 0.84)233 fewer per 1000 (from 117 fewer to 328 fewer)⊕⊕⊕○
MODERATE
CRITICAL
73%234 fewer per 1000 (from 117 fewer to 329 fewer)
Non-remission - vs Placebo
9randomised trialsno serious limitationsserious1no serious indirectnessno serious imprecisionnone921/1508 (61.1%)935/1363 (68.6%)RR 0.88 (0.82 to 0.94)82 fewer per 1000 (from 41 fewer to 123 fewer)⊕⊕⊕○
MODERATE
CRITICAL
71.1%85 fewer per 1000 (from 43 fewer to 128 fewer)
Non-remission - Escitalopram 10mg vs Placebo
3randomised trialsno serious limitationsserious2no serious indirectnessno serious imprecisionnone397/639 (62.1%)331/506 (65.4%)RR 0.92 (0.81 to 1.06)52 fewer per 1000 (from 124 fewer to 39 more)⊕⊕⊕○
MODERATE
CRITICAL
66.1%53 fewer per 1000 (from 126 fewer to 40 more)
Mean endpoint depression scores (clinician-rated) - vs Placebo (better indicated by lower scores) (Better indicated by lower values)
6randomised trialsno serious limitationsserious1no serious indirectnessno serious imprecisionnone903918-SMD 0.24 lower (0.35 to 0.13 lower)⊕⊕⊕○
MODERATE
CRITICAL
Mean endpoint depression scores (clinician-rated) - Escitalopram 10mg vs Placebo (Better indicated by lower values)
3randomised trialsno serious limitationsserious2no serious indirectnessno serious imprecisionstrong association4476488-SMD 0.23 lower (0.46 to 0.01 lower)⊕⊕⊕⊕
HIGH
CRITICAL
Mean endpoint depression scores (clinician-rated) - Escitalopram 20mg vs Placebo (Better indicated by lower values)
1randomised trialsno serious limitationsserious3no serious indirectnessno serious imprecisionnone123119-SMD 0.46 lower (0.71 to 0.2 lower)⊕⊕⊕○
MODERATE
CRITICAL
Mean endpoint depression scores (clinician-rated) - vs Placebo (Better indicated by lower values)
10randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone15331397-SMD 0.26 lower (0.34 to 0.19 lower)⊕⊕⊕⊕
HIGH
CRITICAL
Mean change depression scores (clinician-rated) - Escitalopram 10mg vs Placebo (Better indicated by lower values)
3randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious5none580445-SMD 0.28 lower (0.41 to 0.15 lower)⊕⊕⊕○
MODERATE
CRITICAL
Mean change depression scores (clinician-rated) - Escitalopram 20mg vs Placebo (Better indicated by lower values)
1randomised trialsno serious limitationsserious3no serious indirectnessno serious imprecisionnone123119-SMD 0.48 lower (0.74 to 0.22 lower)⊕⊕⊕○
MODERATE
CRITICAL
Leaving treatment early for any reason - vs Placebo
11randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone413/1881 (22%)309/1614 (19.1%)RR 1.11 (0.95 to 1.29)21 more per 1000 (from 10 fewer to 56 more)⊕⊕⊕⊕
HIGH
CRITICAL
19.3%21 more per 1000 (from 10 fewer to 56 more)
Leaving treatment early for any reason - Escitalopram 10mg vs Placebo
4randomised trialsno serious limitationsserious1no serious indirectnessserious6none151/758 (19.9%)119/628 (18.9%)RR 0.99 (18.9%) (0.75 to 1.3)2 fewer per 1000 (from 47 fewer to 57 more)⊕⊕○○
LOW
CRITICAL
20%2 fewer per 1000 (from 50 fewer to 60 more)
Leaving treatment early for any reason - Escitalopram 20mg vs Placebo
1randomised trialsno serious limitationsserious3no serious indirectnessserious6none36/125 (28.8%)30/122 (24.6%)RR 1.17 (0.77 to 1.77)42 more per 1000 (from 57 fewer to 189 more)⊕⊕○○
LOW
CRITICAL
24.6%42 more per 1000 (from 57 fewer to 189 more)
Leaving treatment early due to side effects - vs Placebo
11randomised trialsno serious limitationsserious1no serious indirectnessno serious imprecisionnone117/1855 (6.3%)51/1601 (3.2%)RR 1.8 (1.18 to 2.73)25 more per 1000 (from 6 more to 55 more)⊕⊕⊕○
MODERATE
CRITICAL
3%24 more per 1000 (from 5 more to 52 more)
Leaving treatment early due to side effects - Escitalopram 10mg vs Placebo
4randomised trialsno serious limitationsserious2no serious indirectnessserious6none45/758 (5.9%)18/628 (2.9%)RR 2.02 (0.9 to 4.54)29 more per 1000 (from 3 fewer to 101 more)⊕⊕○○
LOW
CRITICAL
2.6%27 more per 1000 (from 3 fewer to 92 more)
Leaving treatment early due to side effects - Escitalopram 20mg vs Placebo
1randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessserious7none13/125 (10.4%)3/122 (2.5%)RR 4.23 (1.24 to 14.47)79 more per 1000 (from 6 more to 331 more)⊕⊕⊕○
MODERATE
CRITICAL
2.5%81 more per 1000 (from 6 more to 337 more)
Patients reporting side effects - vs Placebo
8randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone932/1299 (71.7%)771/1191 (64.7%)RR 1.09 (1.04 to 1.15)58 more per 1000 (from 26 more to 97 more)⊕⊕⊕⊕
HIGH
CRITICAL
66.5%60 more per 1000 (from 27 more to 100 more)
Patients reporting side effects - Escitalopram 10mg vs Placebo
3randomised trialsno serious limitationsno serious inconsistencyno serious indirectnessno serious imprecisionnone295/483 (61.1%)288/491 (58.7%)RR 1.04 (0.94 to 1.15)23 more per 1000 (from 35 fewer to 88 more)⊕⊕⊕⊕
HIGH
CRITICAL
56.1%22 more per 1000 (from 34 fewer to 84 more)
Patients reporting side effects - Escitalopram 20mg vs Placebo
1randomised trialsno serious limitationsserious3no serious indirectnessno serious imprecisionnone107/125 (85.6%)86/122 (70.5%)RR 1.21 (1.06 to 1.39)148 more per 1000 (from 42 more to 275 more)⊕⊕⊕○
MODERATE
CRITICAL
70.5%148 more per 1000 (from 42 more to 275 more)
1

Moderate heterogeneity

2
3

Single study

4

Large studies

5

Unclear clinical importance

6

Inconclusive effect size

7

Large confidence interval

From: APPENDIX 16, CLINICAL EVIDENCE PROFILES

Cover of Depression
Depression: The Treatment and Management of Depression in Adults (Updated Edition).
NICE Clinical Guidelines, No. 90.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): British Psychological Society; 2010.
Copyright © The British Psychological Society & The Royal College of Psychiatrists, 2010.

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