Comparison of two treatment strategies in inpatients with a depressive disorder: a
double-blind study of imipramine followed by lithium addition versus fluvoxamine
followed by lithium addition
background There is still uncertainty regarding the best treatment option for depressed inpatients and the best strategy to follow if patient response is insufficient.
aim To compare the efficacy of imipramine and fluvoxamine in depressed inpatients who subsequently received lithium supplement in case of poor response.
method After a drug-free period and four days of placebo use, patients were randomised either to imipramine or to fluvoxamine (phase 1); the antidepressant dosage was fixed according to a predetermined plasma level. The efficacy of the antidepressant was evaluated four weeks after the predetermined plasma level had been attained. If patient response was inadequate, the antidepressant was augmented with lithium (phase 2). Patient response to the lithium addition was evaluated three weeks after an adequate lithium level had been attained.
results The study involved 138 inpatients. At the end of phase 1, imipramine was found to be superior to fluvoxamine according to the Clinical Global Impression of Improvement. Remission was achieved by 16 (23%) patients on imipramine and by 10 (15%) patients on fluvoxamine; this difference was not statistically significant. At the end of phase 2, 41 (59%) patients on imipramine and 27 (40%) patients on fluvoxamine achieved remission, this significant difference demonstrating the superiority of the imipramine strategy.
conclusion Imipramine with subsequent lithium addition is superior to a similar strategy with fluvoxamine.