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Systematic Review and Meta-analysis

Matthew J. Taylor, MRCPsych; Nick Freemantle, PhD; John R. Geddes, MD; Zubin Bhagwagar, DPhil

Arch Gen Psychiatry. 2006;63:1217-1223.

Context  Selective serotonin reuptake inhibitors (SSRIs) are often described as having a delayed onset of effect in the treatment of depression. However, some trials have reported clinical improvement as early as the first week of treatment.

Objective  To test the alternative hypotheses of delayed vs early onset of antidepressant action with SSRIs in patients with unipolar depression.

Data Sources  Trials identified by searching CENTRAL, The Cochrane Collaboration database of controlled trials (2005), and the reference lists of identified trials and other systematic reviews.

Study Selection  Randomized controlled trials of SSRIs vs placebo for the treatment of unipolar depression in adults that reported outcomes for at least 2 time points in the first 4 weeks of treatment (50 trials from >500 citations identified). Trials were excluded if limited to participants older than 65 years or specific comorbidities.

Data Extraction  Data were extracted on trial design, participant characteristics, and outcomes by a single reviewer.

Data Synthesis  Pooled estimates of treatment effect on depressive symptom rating scales were calculated for weeks 1 through 6 of treatment. In the primary analysis, the pattern of response seen was tested against alternative models of onset of response. The primary analysis incorporated data from 28 randomized controlled trials (n = 5872). A model of early treatment response best fit the experimental data. Treatment with SSRIs rather than placebo was associated with clinical improvement by the end of the first week of use. A secondary analysis indicated an increased chance of achieving a 50% reduction in Hamilton Depression Rating Scale scores by 1 week (relative risk, 1.64; 95% confidence interval, 1.2-2.25) with SSRI treatment compared with placebo.

Conclusions  Treatment with SSRIs is associated with symptomatic improvement in depression by the end of the first week of use, and the improvement continues at a decreasing rate for at least 6 weeks.

Author Affiliations: Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, England (Drs Taylor and Geddes); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn (Dr Bhagawar); and Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham, England (Dr Freemantle).

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