Home' Australian Pharmacist : Australian Pharmacist September 2012 Contents Australian Pharmacist September 2012 I ©Pharmaceutical Society of Australia Ltd. 713
The e cacy of citalopram for
By Dr Hanan Khalil
Dr Hanan Khalil is the Director of the Centre for
Chronic Disease Management, a collaborating
centre of the Joanna Briggs Institute, Faculty of
Medicine, Nursing and Health Sciences, Monash
University, and a reviewer for the consumer
group of the Cochrane Collaboration.
This evidence represents the best
available evidence regarding the e cacy
of citalopram over other antidepressants
for the treatment of depression. For the
full review refer to Cipriani A, Purgato M,
Furukawa TA, et al. Citalopram versus other
anti-depressive agents for depression.
Cochrane Database of Systematic Reviews
2012, Issue 7. Art. No.: CD006534.DOI:
Major depression represents the third
leading cause of disability among all
diseases and is expected to be the leading
cause by 2030.2 Both pharmacological
and psychological interventions are
e ective for managing major depression.
Pharmacological treatments remain the
mainstay for most patients with depression.
Several classes of drugs are used
including tricyclic antidepressants (TCAs),
monoamine oxidase inhibitors (MAOs),
selective serotonin uptake inhibitors (SSRIs)
and serotonin noradrenaline reuptake
inhibitors (SNRIs), as well as other agents
such as mirtazipine, reboxetine and
bupropion.3 SSRIs are widely prescribed and
are generally more accepted than TCAs due
to their low side e ects pro le. The e cacy
and adverse side e ects of citalopram in
comparison with TCAs, MAOIs, SSRIs, SNRIs
and other antidepressants in the acute-
phase treatment of major depression were
evaluated in the above mentioned review
as part of the rubric of the Meta-Analyses of
New Generation Antidepressants (MANGA)
Study Group to systematically review all
available evidence for each speci c newer
Characteristics of the studies
and the interventions
The studies included in the above
mentioned review were all randomised
controlled trials examining the e cacy
of citalopram with all other active
antidepressants as monotherapy in the
acute phase treatment of depression.
The participants included in the above
review were patients 18 years or older, of
both sexes, with a primary diagnosis of
depression using standardised criteria.
Quality of the research
The methodological quality of the included
studies was judged on randomisation,
allocation, blinding, incomplete data and
selective reporting. Overall, the grading of
the studies was poor to moderate as most
were done a while ago and were measured
according to today's research standards.
• Several databases were searched
including the Cochrane Collaboration
Depression, Anxiety and Neurosis
Controlled Trials Register and the
Cochrane Central Register of Controlled
Trials (CCDANCTR) up to February 2012,
MEDLINE (1966 to 2012) and EMBASE
(1974 to 2012).
• Other databases of drug-approving
agencies for published, unpublished
and ongoing controlled trials were also
searched. These included the Food and
Drug Administration (FDA) in the USA,
the Medicines and Healthcare products
Regulatory Agency (MHRA) in the UK,
the European Medicines Agency (EMA) in
the EU, the Pharmaceuticals and Medical
Devices Agency (PMDA) in Japan and the
Therapeutic Goods Administration (TGA)
• A total of 37 studies were included in the
above review. Of these, four trials were
• The primary outcomes measure was
e cacy at six to 12 weeks represented by
the number of patients who responded to
• The secondary outcomes include e cacy
at di erent stages of treatment such as
early stage (one to four weeks), remission
and after 16 weeks, acceptability and
• Citalopram was shown to be signi cantly
less bene cial than escitalopram in
achieving acute response (odds ratio
(OR) 1.47, 95% con dence interval (CI)
1.08 to 2.02), but more e cacious than
paroxetine (OR 0.65, 95% CI 0.44 to 0.96)
and reboxetine (OR 0.63, 95% CI 0.43 to
• Only a few patients allocated to citalopram
withdrew from trials due to adverse events
compared with patients allocated to
tricyclic antidepressants (OR 0.54, 95% CI
0.38 to 0.78).
• Patients on citalopram reported fewer side
e ect than reboxetine or venlafaxine (OR
0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95%
CI 0.24 to 0.88, respectively).
Implications for practice and
Most of the studies included in the above
mentioned review were sponsored by drug
companies and were poorly designed due
to their short term follow up period. Patients'
relevant outcomes measures were also
not included in the review. Information on
outcomes such as hospitalisation, quality
of life, return to work and social functioning
may be helpful to guide appropriate
treatment. More research is needed on
good quality studies addressing relevant
According to the systematic review
mentioned above, citalopram was found to
be more e ective than other antidepressants
such as paroxetine and reboxetine for
moderate-to-severe acute major depression,
and it was overall well-tolerated.
1. Cipriani A, PurgatoM, Furukawa TA, et al. Citalopram versus
other anti-depressive agents for depression. Cochrane Database
of Systematic Reviews 2012, Issue 7. Art. No.: CD006534.DOI:
2. American Psychiatric Association. Practice guidelines for
the treatment of psychiatric disorders: Compendium 2006.
American Psychiatric Association; 2006.
3. American Psychiatric Association. Practice guideline for the
treatment of patients with major depressive disorder (revision).
Am J Psychiatry 2000;157(4 Suppl):1--45.
4. Barbui C, Cipriani A, Brambilla P, et al. 'Wish bias' in antidepressant
drug trials? J Clin Psychopharmacol 2004;24(2):126--30.
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