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Comparative Effectiveness Review Number 215 R Adverse Effects of Pharmacological Treatments of Major Depression in Older Adults Comparative Effectiveness Review Number 215 Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No. 290-2015-00012-I Prepared by: University of Connecticut Evidence-based Practice Center Storrs, CT Investigators: Diana M. Sobieraj, Pharm.D. William L. Baker, Pharm.D. Brandon K. Martinez, Pharm.D. Adrian V. Hernandez, M.D., Ph.D. Craig I. Coleman, Pharm.D. Joseph S. Ross, M.D., M.H.S. Karina M. Berg, M.D., M.S. David C. Steffens, M.D. AHRQ Publication No. 19-EHC011-EF March 2019 Key Messages Purpose of Review To assess adverse events of antidepressants in the treatment of major depressive disorder in adults 65 years of age or older. Key Messages In people 65 years of age or older: • Serotonin norepinephrine reuptake inhibitors (SNRIs) (duloxetine and venlafaxine) cause adverse events more often than placebo and most likely lead to discontinuation of therapy during treatment of up to 12 weeks. • Selective serotonin reuptake inhibitors (SSRIs) (escitalopram and fluoxetine) most likely cause adverse events at a similar frequency to placebo therapy but still may lead to discontinuation of therapy during treatment of up to 12 weeks. • Duloxetine most likely increases the risk of falls over longer treatment (<24 weeks) • Adverse events contributing to discontinuation of therapy were rarely reported in a way that allowed clear characterization of what adverse events to expect. • Few studies compared other antidepressants to placebo or to each other, or reported other outcomes. Trial data were sparse, and trials were short in duration, underpowered, and studied low doses of antidepressants. Observational studies had limitations related to their design. Long-term, rigorous comparative studies are needed. ii This report is based on research conducted by the University of Connecticut Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00012-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report. The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients. This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders. AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied. This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program website at www.effectivehealthcare.ahrq.gov. Search on the title of the report. Persons using assistive technology may not be able to fully access information in this report. For assistance contact [email protected]. Suggested citation: Sobieraj DM, Baker WL, Martinez BK, Hernandez AV, Coleman CI, Ross JS, Berg KM, Steffens DC. Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults. Comparative Effectiveness Review No. 215. (Prepared by the University of Connecticut Evidence-based Practice Center under Contract No. 290-2015-00012-I.) AHRQ Publication No. 19-EHC011-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER215. iii Preface The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of systematic reviews to assist public- and private-sector organizations in their efforts to improve the quality of healthcare in the United States. These reviews provide comprehensive, science-based information on common, costly medical conditions, and new healthcare technologies and strategies. Systematic reviews are the building blocks underlying evidence-based practice; they focus attention on the strength and limits of evidence from research studies about the effectiveness and safety of a clinical intervention. In the context of developing recommendations for practice, systematic reviews can help clarify whether assertions about the value of the intervention are based on strong evidence from clinical studies. For more information about AHRQ EPC systematic reviews, see www.effectivehealthcare.ahrq.gov/reference/purpose.cfm. AHRQ expects that these systematic reviews will be helpful to health plans, providers, purchasers, government programs, and the healthcare system as a whole. Transparency and stakeholder input are essential to the Effective Health Care Program. Please visit the website (www.effectivehealthcare.ahrq.gov) to see draft research questions and reports or to join an email list to learn about new program products and opportunities for input. If you have comments on this systematic review, they may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD 20857, or by email to [email protected]. Gopal Khanna, M.B.A. Arlene S. Bierman, M.D., M.S. Director Director Agency for Healthcare Research and Quality Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality Stephanie Chang, M.D., M.P.H. Aysegul Gozu, M.D., M.P.H. Director Task Order Officer Evidence-based Practice Center Program Center for Evidence and Practice Center for Evidence and Practice Improvement Improvement Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality iv Acknowledgments The authors gratefully acknowledge the contribution of the EPC librarian, Sharon Giovenale, for her contribution to the literature search and citation retrieval process. We would like to acknowledge the affiliations of our content experts: Karina M. Berg, M.D., M.S. Associate Professor of Medicine, Center on Aging University of Connecticut School of Medicine Farmington, CT Joseph S. Ross, M.D., M.H.S. Associate Professor of Medicine and Public Health Yale University School of Medicine, School of Public Health New Haven, CT David C. Steffens, M.D. Professor and Chair of Psychiatry University of Connecticut School of Medicine Farmington, CT Key Informants In designing the study questions, the EPC consulted several Key Informants who represent the end-users of research. The EPC sought the Key Informant input on the priority areas for research and synthesis. Key Informants are not involved in the analysis of the evidence or the writing of the report. Therefore, in the end, study questions, design, methodological approaches, and/or conclusions do not necessarily represent the views of individual Key Informants. Key Informants must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Because of their role as end-users, individuals with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any conflicts of interest. The list of Key Informants who provided input to this report follows: Iqbal Ahmed, M.D. University of Hawaii Honolulu, HI Peter Ajuonuma, J.D., M.B.A., R.N. Centers for Medicare & Medicaid Services Baltimore, MD Rebecca Andrews, M.D. University of Connecticut School of Medicine Farmington, CT v Nicole Brandt, Pharm.D., M.B.A. University of Maryland School of Pharmacy Baltimore, MD Lisa Hines, Pharm.D. Pharmacy Quality Alliance Alexandria, VA Jean Kim, M.D. U.S. Food and Drug Administration Silver Spring, MD George Niederehe, Ph.D. National Institute of Mental Health Bethesda, MD Michael Steinman, M.D. University of California, San Francisco School of Medicine San Francisco, CA Technical Expert Panel In designing the study questions and methodology at the outset of this report, the EPC consulted several technical and content experts. Broad expertise and perspectives were sought. Divergent and conflicted
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