The edition · Psychiatry
Escitalopram and amitriptyline lengthen QTc most, but trials show no early cardiac events from antidepressants
An individual-participant analysis of double-blind trials ranks ten antidepressants by QTc effect, an observational review links antidepressants to ventricular arrhythmia, cannabis is tied to violence both committed and suffered, and two trials — Open Dialogue and paediatric anxiety sequencing — report null primary outcomes with useful secondaries.
The edition in brief
An individual participant data network meta-regression of 35 double-blind trials (8679 adults with depression) found escitalopram lengthened QTc by 8.7 ms (95% CrI 1.6 to 15.8) and amitriptyline by 5.3 ms (0.8 to 9.8) against placebo over eight weeks; venlafaxine and vortioxetine had the smallest effects. Across 139 trials (52,398 people), antidepressants were not associated with early major cardiovascular events or non-suicidal death (risk difference 0.01%). A separate meta-analysis of 12 observational studies associated antidepressant use with ventricular arrhythmia or sudden cardiac death (OR 1.34, 1.15 to 1.55), with very high heterogeneity and likely confounding by depression itself; the atrial fibrillation signal was uncertain. A meta-analysis of 63 studies found cannabis use was associated with perpetrating violence in psychiatric patients (OR 2.49) and the general population (OR 2.05), and with being a victim (OR 1.49). The ODDESSI cluster trial found Open Dialogue did not delay relapse after a crisis (HR 0.95, 0.67 to 1.32) but was associated with fewer admissions and better patient-rated outcomes. In 316 young people with anxiety, starting with fluoxetine or CBT gave similar results, and adding the other treatment in non-remitters did not beat continuing monotherapy. The practical message: choose antidepressants with the individual's QTc risk factors in mind, and ask about cannabis routinely.
Cannabis use is associated with both committing and suffering violence
Ask routinely about cannabis in psychiatric assessments; it marks a higher risk of violence both committed and suffered.
Observational data link antidepressants to ventricular arrhythmia, with heavy confounding
Antidepressants are associated with ventricular arrhythmia in observational data, but confounding by depression cannot be excluded.
Open Dialogue did not delay relapse after a crisis but was associated with fewer admissions
Open Dialogue did not reduce relapse after a mental health crisis, though admissions and patient experience favoured it.
In childhood anxiety, starting with fluoxetine or CBT made no difference, and switching to combination did not help non-remitters
For childhood anxiety, start with fluoxetine or CBT according to family preference and access; both did equally well.
A three-point QTc check before starting an antidepressant
Use cardiac history, electrolytes and co-prescribed drugs to decide who needs an ECG before an antidepressant.
Escitalopram and amitriptyline lengthened QTc most, but antidepressants showed no early cardiac events in trials
Choose the antidepressant with the person's QT risk factors in mind: escitalopram and amitriptyline prolonged QTc most, while early cardiac events were not increased.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for psychiatry, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free