The trial by Hochstrasser et al (2001, this issue) provides a timely reminder of the need for such prolonged treatment of recurrent unipolar depression and reinforces the evidence base and conclusions regarding prolonged treatment of recurrent depression in the BAP guidelines (Anderson et al, 2000). In this study the authors examined the prophylactic effect of the selective serotonin reuptake inhibitor citalopram in unipolar recurrent depression.
The aim of the study was to compare the prophylactic efficacy of citalopram and placebo and also to determine the long-term tolerability of citalopram. In- and out-patients between the ages of 18 and 65 years, all of whom had to satisfy standardised diagnostic and severity criteria and have had two or more episodes of depression with at least one of these occurring within the past 5 years, were included in the study.
Treatment consisted of citalopram (20-60 mg) for 6-9 weeks, with continuation treatment with citalopram for a further 15 weeks for patients responding to acute treatment. Patients then were assigned to double-blind maintenance treatment with citalopram or placebo for 48-77 more weeks, with the citalopram maintained at the dose that was efficacious in acute treatment.
The main outcome measure was the eminently pragmatic one of time to recurrence of a new depressive episode. The results of the trial show that the time to recurrence of depression was significantly longer in the patients taking citalopram and that the advantage of citalopram over placebo was significant at all doses.
FUTURE DIRECTIONS
Although evidence continues to accumulate that selective serotonin reuptake inhibitors are effective and well tolerated during long-term treatment of recurrent unipolar depression, questions remain regarding long-term prophylactic treatment of recurrent depression. In this study, the difference in outcome between the citalopram- and placebo-treated groups was still evident at the end of the study period and the optimal duration of treatment therefore remains unclear. Finally, because most depressive illnesses will be treated in primary care, utilisation of currently effective treatments should be maximised by general practitioners, although recent attempts to foster this with guidelines have proved somewhat disappointing (Thompson et al, 2000).
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Received for publication June 19, 2000. Revision received November 6, 2000. Accepted for publication November 22, 2000.
A. H. YOUNG, MRCPsych
Department of Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne NEI 4LP, UK
