The use of antidepressants is not associated with significantly better health-related quality of life

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Over time, using antidepressants is not associated with significantly better health-related quality of life, compared to people with depression who do not take the drugs.

These are the findings of a new study published this week in the open-access journal PLOS ONE by Omar Almohammed of King Saud University, Saudi Arabia, and colleagues.

It is generally well known that depression disorder has a significant impact on the health-related quality of life (HRQoL) of patients. While studies have shown the efficacy of antidepressant medications for treatment of depression disorder, these medications’ effect on patients’ overall well-being and HRQoL remains controversial.

In the new study, the researchers used data from the 2005-2015 United States’ Medical Expenditures Panel Survey (MEPS), a large longitudinal study that tracks the health services that Americans use. Any person with a diagnosis of depression disorder was identified in the MEPS files.

Over the duration of the study, on average there were 17.47 million adult patients diagnosed with depression each year with two years of follow-up, and 57.6% of these received treatment with antidepressant medications.

Use of antidepressants was associated with some improvement on the mental component of SF-12—the survey tracking health-related quality of life.

However, when this positive change was compared to the change in group of people who were diagnosed with depressive disorder but did not take antidepressants, there was no statistically significant association of antidepressants with either the physical (p=0.9595) or mental (p=0.6405) component of SF-12.

In other words, the change in quality of life seen among those on antidepressants over two years was not significantly different from that seen among those not taking the drugs.

The study was not able to separately analyze any subtypes or varying severities of depression. The authors say that future studies should investigate the use of non-pharmacological depression interventions used in combination with antidepressants. 

The authors add: “Although we still need our patients with depression to continue using their antidepressant medications, long-term studies evaluating the actual impact for pharmacological and non-pharmacological interventions on these patients’ quality of life is needed.

“With that being said, the role of cognitive and behavioral interventions on the long term-management of depression needs to be further evaluated in an efforts to improve the ultimate goal of care for these patients; improving their overall quality of life.”


Antidepressants are a common and effective strategy for treating MDD; however, remission rates are typically low, and factors affecting antidepressant response are poorly understood. This study is the largest genetic investigation of antidepressant response based on clinically defined cohorts. For the first time, we identify a polygenic profile for antidepressant response, which can predict across cohorts, and shows genetic correlations with traits that reflect clinical observations.

This study finds significant evidence that antidepressant response is influenced by common genetic variation. Meta-analysis of SNP-based heritability estimates within each cohort indicates that 20% to 40% of the variance in antidepressant response is attributable to common genetic variation, consistent with a previous analysis of a subset of these studies (20).

However, the SNP-based heritability decreased substantially when estimating across cohorts simultaneously. Although the change in SNP-heritability was not statistically significant, these results suggest that antidepressant response in a broad context has a heritable component, but genetic differences can explain additional variability in antidepressant response within more specific contexts.

Despite the apparent heterogeneity across individual cohorts, the sample sizes for antidepressant response are sufficiently large to detect a polygenic signal. Genetic studies for susceptibility to psychiatric disorders show that findings accrue after an inflection point in sample size is reached (30, 31, 32).

This study’s findings for SNP-based heritability and out-of-sample polygenic prediction indicate that sample sizes for antidepressant response are reaching the inflection point and that larger studies will uncover more of the genetic component (44). Power calculations for detecting genome-wide significant variation, and the variance explained by corresponding polygenic scores, are provided in Figure S25 in Supplement 1.

Interestingly, our findings suggest that the SNP-based heritability of remission is higher than for percentage improvement. The percentage improvement score might have lower heritability because of increased noise, in which this measure is more susceptible to random variation in depressive symptoms, is less comparable across the different depressive symptom scales used, or captures increases in depressive symptoms.

This study provides novel insight into the shared genetic basis between antidepressant response and mental health phenotypes. We show an association between high genetic liability of psychiatric disorders and poorer response, which mirrors conclusions of clinical studies (45). The schizophrenia polygenic risk score was negatively associated with antidepressant response, which is replicated in the TRD phenotype in Generation Scotland.

Previous studies have shown that individuals with TRD may respond to antipsychotic medication (46). Our findings extend those reports by suggesting that individuals with antidepressant resistance also have a higher burden of schizophrenia genetic risk. We found some evidence that genetic liability to major depression is associated with poorer response to antidepressants. However, this association was only statistically significant for percentage improvement, and it requires replication. In addition, we report a novel finding that high ASD genetic liability increased the chance of remission.

Another recent study reported that ASD genetic liability is associated with poorer response to cognitive behavioral therapy (47). If both these findings are replicated, it would suggest ASD genetic liability could serve as a differential predictor of response to antidepressants and cognitive behavioral therapy. We also identified a significant association between genetic propensity for educational attainment and improved antidepressant response as well as between genetic propensity for educational attainment and non-TRD.

This may reflect the indirect measurement of socioeconomic status captured by educational attainment, which is supported by previous literature showing a positive association between antidepressant response and socioeconomic status (48). Future research should explore whether individuals with higher educational attainment have improved response due to factors such as adherence or joint psychological treatment.

Polygenic scores derived from the remission and percentage improvement GWASs both significantly predicted antidepressant response out of sample using a leave-one-out design. This is the first GWAS of antidepressant response able to predict significantly out of sample, representing an important advance in the field of antidepressant response genetics.

Although the variance explained is low (R2 = 0.1%) and p values are close to the nominal significance threshold, this result is encouraging given the sample size of this study. For example, a recent GWAS of MDD explains only 1.9% of the variance in MDD, despite having a sample size 100 times greater than this study (30). Our finding suggests that a renewed effort to systematically collect new samples in which genetic associations with antidepressant response can be identified will improve the prediction of antidepressant response, helping to uncover its biological mechanisms and clinical associations, and eventually enable more accurate clinical predictors to be developed and applied.

This study provided limited insight into the biological underpinnings of antidepressant response implicating one locus on chromosome 17 surrounding ETV4 and DHX8. A previous study using neuronal cell lines and mouse models found that ETV4 mediates brain-derived neurotrophic factor (BDNF) induced hippocampal dendrite development and plasticity (49), congruent with the hypothesis that the mechanism of action for antidepressants is via hippocampal neuroplasticity (50). DHX8 has a less clear mechanistic link to antidepressant response with a broader function in messenger RNA splicing (51). Replication of the association at this locus is required before further experimental investigation.

In addition, no association was detected with genetic variation within classical pharmacokinetic candidate genes, such as CYP2D6 and CYP2C19, which have previously been robustly associated with antidepressant plasma levels (11). Although the enzymatic activity of CYP2D6 and CYP2C19 is largely regulated by common genetic variation, these variants include structural variants that are not well captured by GWAS arrays, and large effects on enzymatic activity are typically conferred by combinations of genetic variants (haplotypes), which GWAS does not assess. Therefore, the absence of an association at this point may be a false negative result. Furthermore, looking across individuals that have not been treated with a specific antidepressant or antidepressant class will reduce the likelihood of detecting pharmacokinetic effects.

Owing to a limited sample size, it was not possible to estimate genetic correlations between longitudinally assessed antidepressant response and TRD defined using electronic health records. However, comparison of shared genetic etiology with other mental health phenotypes indicated that these distinct measures of antidepressant response have a shared genetic basis. Further comparison and integration of these two approaches is warranted and may prove fruitful given the large gains in sample size that electronic health record–derived phenotypes can provide.

There are several limitations to this study that should be addressed in the future. First, large sample sizes are essential for robust identification of associated genetic variation and out-of-sample prediction. However, combining independently collected datasets inevitably introduces heterogeneity. Obtaining large homogeneous samples is particularly challenging for pharmacogenetic studies, as heterogeneity is driven not only by patient characteristics such as diagnosis and patient ascertainment, but also by differences in treatment such as the drug, dosage, duration, and co-pharmacotherapy. Although the cohorts within this study have many features in common, heterogeneity in antidepressant treatment is present.

As sample sizes grow, analyses stratified by these factors will become more feasible, enabling detection of genetic effects relevant to each antidepressant, antidepressant class, or other treatment characteristics. Second, an important question to consider is whether the variance in depressive symptoms after treatment is due to antidepressant response or to other variables altering the course of depression.

Although antidepressants have a significant effect on depressive symptoms, and their administration is the core feature of participants in this study, individuals may vary in depressive symptoms due to other factors affecting disease progression, such as clinical and sociodemographic variables and placebo response.

This is a difficult issue to resolve but should be considered when interpreting the results. Future genetic studies incorporating the placebo arm of clinical trials may help identify genetic associations specific to antidepressant response. Third, this study has focused on changes in total depressive symptoms without considering symptom domain-specific changes or the presence of side effects.

Given the wide range of depressive symptoms and the influence side effects can have on efficacy, consideration of these features may provide additional insights. Fourth, although this study included three cohorts of East Asian ancestry, further inclusion of cohorts with diverse ancestries is an important area. Genetic analysis within diverse populations helps to ensure that the findings are applicable to worldwide populations and can help fine-map causal variants underlying genetic associations.

In summary, this study identifies a polygenic profile for antidepressant response that predicts across studies and is negatively correlated with genetic susceptibility to schizophrenia, which could be used for prognostic purposes. While the current results have no clinical utility as a pharmacogenetic test, they indicate that studies with larger sample sizes could provide predictions explaining a substantial proportion of antidepressant response.

We note that a prognostic test that enables even a modest increase in the proportion of patients that respond to antidepressants would have a substantial impact on recovery for many patients, given the high prevalence of depression. We hope that this study prompts both replication and extension to accelerate the development of pharmacogenetic testing for psychiatry.

reference link : https://www.sciencedirect.com/science/article/pii/S2667174321000859


Original Research: Open access.
Antidepressants and health-related quality of life (HRQoL) for patients with depression: Analysis of the medical expenditure panel survey from the United States” by Omar Almohammed et al. PLOS ONE

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