[Antidepressants for treatment of depression in palliative patients : a systematic literature review].

BACKGROUND: Treatment of depression in palliative care must take into account expected benefits and risks of antidepressants in patients with potentially limited life expectancy, poor medical condition, advanced age and higher risk to suffer from side effects and drug interactions. This systematic review assesses evidence of the efficacy and safety of different classes of antidepressants depending on the type and severity of the physical illness.
METHODS: A systematic database search (Medline, EMBASE) for clinical studies was carried out and references of identified literature were checked. To be included in the review studies had to be performed in illnesses that were part of in the search strategy, such as multiple sclerosis, Parkinson's disease, Alzheimer's disease, HIV/AIDS, cancer, COPD and heart failure. Considered were controlled studies comparing the efficacy of antidepressants to placebo, other classes of antidepressants, benzodiazepines, psychostimulants or psychotherapy. In a first step only studies with patients meeting established diagnostic criteria of depression and where depression was a primary endpoint were included. In a second step, additional studies were included that did not meet both of the latter criteria but were performed in patients at the end of life.
RESULTS: A total of 40 trials (mostly using SSRI or NSMRI) were included, 16 studies were performed in neurological, 24 in general medical conditions and 9 studies were performed in patients at the end of life or in advanced disease stages. Due to heterogeneous study designs no conclusions can be drawn if efficacy or tolerability is dependent on disease severity. In most cases, studies might have been too small to detect limited treatment effects. As a lack of efficacy was predominantly shown in larger trials, publication bias might have been present. In most of the reviewed general medical conditions study results were heterogeneous. In contrast to the popularity of the treatment approach, results suggest that SSRIs are not effective in Alzheimer's disease. In Parkinson's disease, negative studies are too small to prove lack of efficacy of SSRIs as present in the majority of trials.
CONCLUSIONS: This review of the evidence allows only limited conclusions concerning the use of antidepressants in physical illness disorders at the end of life. The reviewed evidence does not allow direct conclusions to be drawn concerning the use of antidepressants in different disease severities and its benefits compared to other treatment options (psychotherapy, benzodiazepines etc.). The English full text version of this article will be available in SpringerLink as of November 2012 (under "Supplemental").