Depression
Figure 1: Patients in Remission During the 12-month Extension Study (Observed Cases)
100 75 55 25 0
Total number of patients
time. Studies indicate that rates of remission with escitalopram continue to improve over time. In a three-month surveillance study of 5,175 escitalopram-treated patients in Greece, the rate of remission (i.e. CGI-S ≤2) rose from 27.6% at the end of the first month to 60.4% at end-point.7
0248 12 16 20 24 Week
588 582 579 564 538 523 513 498 489 486 471 463 454 439 438
Remission defined as Montgomery-Asberg Depression Rating Scale (MADRS) total score ≤12. Source: Wade et al., 2006.9
Figure 2: Change in Clinical Global Impression-Severity Score as a Function of Baseline Severity
Treatment (months) 0 -1 -2 LOCF (n=4,912) -3
CGI-S = Clinical Global Impression-Severity; LOCF = last observation carried forward. Source: Stamouli et al., 2006.7
01 2 -0.66
-1.15 -1.55
-1.05
-1.89 -2.55
Escitalopram delivers this. In the NAVIGADE study, 78% of patients achieved remission with escitalopram within six months, despite more than half of the patient population experiencing severe depression. This finding is also reflected in the Möller et al. study of 11,760 German patients treated in a naturalistic setting, where the largest decrease in MADRS score was seen in the group of patients with the most severe depression at baseline (i.e. MADRS >30): a mean drop of 22.9 points over eight weeks.5
These results are borne out in practice-based studies as well. In a very large (n=11,760) eight-week open-label trial conducted under naturalistic conditions in Germany, 40.7% of patients were deemed ‘much’ or ‘very much’ improved by their physicians (CGI ≤2) within two weeks.5
By week
eight, nearly 70% of patients were responders (≥50% decrease on the short version of the MADRS) and 56.8% were defined as remitters (MADRS short-version score ≤12). In an open-label eight-week study of 5,453 patients in the US receiving escitalopram treatment, the rate of response (defined as ≤2 on the CGI-I) was 68.0% at end-point.6
Reassuringly, the
response rate was comparable in patients who had previously responded to antidepressant treatment, in those with a history of non-response, and in those who had not received antidepressant treatment prior to the trial.
In summary, primary care physicians can expect improvement with escitalopram within the first few weeks, with many patients achieving full remission within two months.
Rates of Remission with Escitalopram in the Medium and Long Term
Primary care physicians also want to ensure that a patient who shows promise with a particular antidepressant will continue to do well over
22
(Correspondingly, the number of patients categorized as severely ill in this study decreased from 60.6% at baseline to just 5.2% after eight weeks of escitalopram treatment.5
) Similar results were
seen in the three-month Greek surveillance study of 5,175 patients. Those with higher baseline CGI-S scores (indicative of more severe illness) experienced a significantly greater degree of improvement (p<0.001) than those with less severe illness (see Figure 2).7
Therefore, escitalopram makes a good first-line choice for patients with depression irrespective of their baseline disease severity.
Most Patients Require Only 10mg of Escitalopram
Because one of the main goals of the primary care physician is to help patients achieve symptomatic improvement as quickly as possible, it is important to choose a therapeutic starting dose, where possible, in order to avoid time-consuming titration schedules. The dose of escitalopram ranges from 10 to 20mg; however, data from both short- and long-term trials in randomized, controlled, and naturalistic settings indicate that roughly two-thirds of patients will achieve the desired response with the 10mg dosage.3–6,8–10
The only study to report on the correlation between the mean daily dose and the baseline severity of
US PSYCHIATRY
3
Mild (CGI-S 2–3) Moderate (CGI-S 4) Severe (CGI-S 5–7)
28 32 36 40 44 48 52
The proportion of patients achieving remission (MADRS ≤12) in this study rose from 44.5% at six weeks to 66.7% at 12 weeks and 77.7% at 24 weeks. This progressive improvement was mirrored by improvements in CGI-I scores and by the patients’ own rating of their improvement on the Patient Global Evaluation (PGE): at end-point, 73.1 and 74.1% of patients were rated ‘much’ or ‘very much’ improved on the CGI-I and the PGE, respectively. In a 12-month open-label extension of two eight-week, double-blind, randomized, controlled escitalopram trials, the proportion of patients in remission (MADRS ≤12) increased steadily from 45.7% at baseline (i.e. after eight weeks of double-blind treatment) to 86.1% at 12 months (see Figure 1).9
Data from a six-month study conducted in primary care centers across Canada (the NAVIGADE study) indicate that rates of response and remission with escitalopram continue to increase over time.8
Efficacy in Patients with Severe Depression
It may come as a surprise to some primary care physicians to learn how severely depressed many of their patients are. In the NAVIGADE study, 55% of the 641 patients enrolled had a baseline MADRS score of ≥30, indicating severe depression.8
This highlights the fact that a first-line
antidepressant should have proven efficacy even in patients with very severe depression.
Change in mean CGI-S score
Percent of patients in remission
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