Efficacité de l’escitalopram et sévérité de la dépression : nouvelles données

Abstract

According to recent data in the literature, severe forms of depression represent almost half of all characterised episodes of depression; in view of this their treatment is a real public health challenge. According to the recommendations of various health authorities, treatment first relies on antidepressant medication. A recent meta-analysis of 12 new generation antidepressants has shown that these products are not all equivalent in the treatment of major depression, and that differences exist in terms not only of efficacy but also of acceptability. These differences in efficacy also appear true in the treatment of severe depression. Very recent publications, with a meta-analysis carried out on large cohorts of patients included in clinical trials, have shown the superior efficacy of escitalopram (which is the most active enantiomer of the racemic component, citalopram) in severe depression (defined by a total score on the MADRS scale > or =30). A pooled analysis by Kilts et al. assessed the response to treatment according to the baseline severity of the depression, under escitalopram and under six comparable products: citalopram, duloxetine, fluoxetine, paroxetine, sertraline, and venlafaxine. It showed that the rate of responders to the different treatments decreased when baseline severity increased, which agrees with the data in the literature, except for escitalopram, with which the rate of responders remained stable. The pooled analysis of Kennedy et al., that partly referred to the same studies, showed that for all the patients exhibiting severe depression, escitalopram was significantly superior to the other same six comparable products (mean estimated difference of 1.8 on the total MADRS score [p<0.0001]; a rate of 64.4 responders vs 55.8% [odds ratio=1.60, p<0.0001]; rate of remission of 47.7 vs 41.6% [odds ratio=1.39, p<0.0007]). In parallel with the statistical significance of the results, the criterion of clinical pertinence of the differences revealed between the medicinal products is highly significant. Regarding antidepressants, the criteria of clinical pertinence most frequently applied are the difference in rate of responders, the number needed to treat (NNT) and, to a lesser extent, the difference between the rates of patients in remission and the difference in the effect of treatment. According to these criteria, Montgomery and Möller (2009) assessed the clinical pertinence of the results showing the superior efficacy of escitalopram on three products: citalopram, paroxetine and duloxetine. Hence, they established this clinical pertinence for all of the depressed patients, but also in the particular case of severe depression. All these new data confirm the interest of escitalopram in the treatment of characterised depression and notably in the severe forms, with a particularly favourable efficacy/acceptability ratio.