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AHCPR releases evidence reports on depression and sinusitis

The Agency for Health Care Policy and Research recently released two new reports—new pharmacotherapies for treating depression and diagnosis and treatment of community-acquired acute sinusitis—from a series of evidence reports/technology assessments sponsored by AHCPR to provide public- and private-sector organizations with comprehensive, science-based information on common, costly medical conditions and health care technologies. AHCPR awarded contracts to 12 Evidence-based Practice Centers (EPCs) in the United States and Canada to review all the relevant literature on designated topics related to prevention, diagnosis, treatment, and management of common diseases and clinical conditions and technology assessments of specific medical procedures or health care technologies.

Forthcoming AHCPR evidence reports/technology assessments examine treatment of attention deficit/hyperactivity disorder, atrial fibrillation, swallowing disorders, and other topics. Recently assigned topics include management of acute chronic obstructive pulmonary disease, management of cancer pain, criteria for weaning from mechanical ventilation, and management of chronic hypertension during pregnancy.

Select to access online summaries of these two evidence reports, treatment of depression, and diagnosis and treatment of acute sinusitis, as well as summaries of earlier reports on cervical cytology, alcohol dependence, urinary tract infections in paralyzed persons, androgen suppression in the treatment of advanced prostatic cancer, sleep apnea and traumatic brain injury. Printed copies of these summaries are available from the AHCPR Publications Clearinghouse, and printed copies of the full reports are expected to be available in the near future.

Treatment of Depression: New Pharmacotherapies. Summary (AHCPR Publication No. 99-E013). Newer categories of antidepressant drugs are equally as effective as older generation antidepressants, and roughly equal numbers of patients drop out of clinical trials because of side effects, according to this evidence report which compares drug treatments for depression. The evidence report was prepared for AHCPR by the San Antonio Evidence-based Practice Center. The EPC found that selective serotonin reuptake inhibitors (SSRIs) are equally as effective in treating depression as older generation antidepressants, such as tricyclics.

According to Cynthia D. Mulrow, M.D., M.Sc., the study's lead investigator and a professor of medicine and geriatrics at the University of Texas Health Science Center at San Antonio, SSRIs are therapies of choice for many practitioners, but there are a lot of treatment options, and no particular class of drugs is routinely more effective than others. The EPC found that both newer and older generation antidepressants have side effects. Patients taking the newer antidepressants were more likely to have higher rates of diarrhea, nausea, insomnia, and headache. The older drugs were likely to cause adverse effects on the heart and blood pressure and result in dry mouth, constipation, dizziness, blurred vision, and/or tremors. Although anecdotal reports suggest high rates of difficulty in sexual functioning, this study found few data that directly address this problem.

The study did not compare drug costs for the nine categories of antidepressants, the dosing schedules, or the risk of various drug-to-drug interactions. The report was designed to provide a comprehensive evaluation of the efficacy of newer pharmacotherapies and herbal medications—such as St. John's wort, kava kava, and valeriana—for depressive disorders.

The researchers found no evidence of effectiveness of kava kava and valeriana and concluded that existing evidence about the effectiveness of St. John's wort is unclear. However, compared with placebo, the literature suggests that St. John's wort shows promise for mild to moderate depression, and it may have fewer adverse effects than older generation antidepressants. The National Institutes of Health, through the National Institute of Mental Health, the National Center on Complementary and Alternative Medicine, and the Office of Dietary Supplements, is now sponsoring a placebo-controlled, blinded clinical trial comparing St. John's wort to a selective serotonin reuptake inhibitor.

Diagnosis and Treatment of Acute Bacterial Rhinosinusitis. Summary (AHCPR Publication No. 99-E015). In treating uncomplicated acute bacterial sinusitis, inexpensive antibiotics like amoxicillin and folate inhibitors are just as effective as newer and more expensive antibiotics such as third generation cephalosporins. However, for many patients with acute sinusitis, symptoms will resolve without any antibiotics. These are the major findings of a study by the New England Medical Center Evidence-based Practice Center.

Acute sinusitis is one of the most common primary care problems in the United States. Millions of cases occur each year, affecting all age groups and all segments of the general population. Although not all people who contract the condition seek treatment from a physician, most still incur costs in buying over-the-counter medications and time lost from work. In 1992, Americans spent $200 million on prescription cold medications and more than $2 billion for over-the-counter medications.

Even though sinusitis is so common, its management is challenging. In most cases, the condition involves inflammation of both the sinuses (sinusitis) and nasal passages (rhinitis), but the causes vary. If the sinusitis is not caused by bacteria, treatment with antibiotics will have limited or no effect and may have adverse side effects. However, because patients with bacterial sinusitis may develop a more serious sinus infection, it is important to properly diagnose and treat these patients. The Center's report focuses on the diagnosis and treatment of uncomplicated, community-acquired, acute bacterial sinusitis in children and adults.

As noted by Joseph Lau, M.D., Director of the New England Medical Center EPC, the research shows that using x-rays or other diagnostic procedures is not a cost-effective initial strategy for uncomplicated patients. He calls for additional research to determine the best ways to screen patients for infections.

In addition, the study concluded that:

  • More patients were cured, and cured earlier, when treated with antibiotics rather than placebo; however, about two-thirds of patients receiving placebos recovered without antibiotics.
  • More research is needed to identify simple, inexpensive, diagnostic methods to help distinguish patients requiring treatment with antibiotics from those not requiring antibiotics or further evaluation.
  • Research focused specifically on children is needed to determine the proper methods to diagnose and treat their sinusitis.
  • Future studies should examine the connection between treatment and relapse rates or the development of recurrent sinusitis. Such results will help clarify the relationship between treatment and the amount of time it takes for symptoms to resolve. Studies also should address the optimal length of antibiotic treatment, the role of patient preferences in clinical decisionmaking, and the issue of emerging antibiotic resistance.

The conclusions about the diagnosis and treatment of acute bacterial sinusitis were based on 48 analyzable studies published within the last 30 years and involving approximately 5,036 patients, including adults and children.

The evidence report was developed by the New England Medical Center EPC in partnership with the American Academy of Otolaryngology-Head and Neck Surgery (AAOHN), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Academy of Family Physicians. The AAOHN, AAP, and ACP each have plans to develop or update clinical guidelines on acute sinusitis.

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