Pharmacological treatments for atypical depression: A systematic review and network meta-analysis of randomized controlled trials.

Background: Atypical depression is a highly prevalent subtype that includes mood reactivity, hypersomnia, and leaden paralysis, necessitating different therapeutic approaches than melancholic depression. No network meta-analysis has been conducted on pharmacological treatments for atypical depression.

Methods: We performed a PRISMA-compliant systematic review and network meta-analysis searching PubMed/Central, Clinicaltrials.gov, Embase, PsycINFO, Scopus, WebOfScience for randomized controlled trials (RCTs) testing pharmacological interventions for atypical depression until 04/24/24 (PROSPERO: CRD42024540262). Depressive symptom change (standardized mean difference/SMD), response, and all-cause discontinuation (acceptability) (risk ratio/RR) were co-primary outcomes; tolerability was the secondary outcome. Risk-of-bias and global/local inconsistencies were measured, and Confidence in Network Meta-Analysis (CINeMA) was used to assess the confidence in the evidence.

Results: Out of 2214 hits, we included 21 eligible RCTs, 20 entering the NMA. For efficacy (k = 16, N = 903, treatments=12), only phenelzine outperformed placebo (SMD=-1.31, 95 %C.I.=[-2.14;-0.49]). Phenelzine, moclobemide, isocarboxazid, imipramine, selegiline, sertraline, and fluoxetine all outperformed nortriptyline (from SMD=-4.54, 95 %C.I.=[-8.02;-1.07] to SMD=-3.08, 95 %C.I.=[-5.42; -0.75]). Regarding response (k = 13, N = 1442, treatments=7), phenelzine (RR=2.58, 95 %C.I.=[2.02-3.31]), sertraline (RR=2.25, 95 %C.I.=[1.01-4.99]), moclobemide (RR=2.16, 95 %C.I.=[1.12-4.19]), fluoxetine (RR=1.89, 95 %C.I.=[1.30-2.76]) and imipramine (RR=1.76, 95 %C.I.=[1.35-2.28]) outperformed placebo, and phenelzine also outperformed imipramine (RR=1.56, 95 %C.I.=[1.25-1.96]). No treatment was significantly different from placebo for acceptability. No intervention outperformed placebo on any outcome in sensitivity analyses upon exclusion of high-risk-of-bias and intention-to-treat trials, likely due to a loss in power of the analysis, and overall CINeMA ratings were low/very low.

Conclusions: Phenelzine might perform better than other compounds, but several drugs outperformed placebo in response. Nortriptyline performed worse than other treatments. High-quality studies are needed.