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21 AUTHORS, INCLUDING:
Robert Keers
Jana Strohmaier
Universitt Heidelberg
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Katherine J Aitchison
Peter Mcguffin
University of Alberta
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ARTICLE
Abstract
The risk of weight gain is an important determinant of the acceptability and tolerability of antidepressant
medication. To compare changes in body weight during treatment with dierent antidepressants, body
weight and height were measured at baseline and after 6, 8, 12 and 26 wk treatment with escitalopram or
nortriptyline in 630 adults with moderate-to-severe unipolar depression participating in GENDEP, a partrandomized open-label study. Weight increased signicantly more during treatment with nortriptyline
compared to escitalopram. The weight gain commenced during the rst 6 wk of nortriptyline treatment,
reached on average 1.2 kg at 12 wk (0.44-point BMI increase), and continued throughout the 6-month
follow-up period. Participants who were underweight at baseline gained most weight. Participants who
were obese at baseline did not gain more weight during treatment. Weight gain occurred irrespective of
whether weight loss was a symptom of current depressive episode and was identied as an undesired
eect of the antidepressant by most participants who gained weight. There was little weight change
during treatment with escitalopram, with an average increase of 0.14 kg (0.05-point BMI increase) over
12 wk of treatment. In conclusion, treatment with the tricyclic antidepressant nortriptyline was associated
with moderate weight gain, which cannot be explained as a reversal of symptomatic weight loss and is
usually perceived as an undesired adverse eect. While treatment with nortriptyline may be recommended in underweight subjects with typical neurovegetative symptoms, escitalopram is a suitable
alternative for subjects at risk of weight gain.
Received 9 April 2010 ; Reviewed 25 May 2010 ; Revised 4 June 2010 ; Accepted 15 July 2010 ;
First published online 18 August 2010
Key words : Antidepressants, adverse eects, body weight, major depressive disorder.
Introduction
A complex relationship exists between depression,
antidepressants and body weight. Although depressive episodes are typically associated with weight loss,
there is a positive association between depression
and obesity in the population (Luppino et al. 2010).
Address for correspondence : Dr R. Uher, P080 SGDP, Institute of
Psychiatry, 16 De Crespigny Park, SE5 8AF, London, UK.
Tel. : +44 207 848 0891 Fax : +44 207 848 0866
Email : rudolf.uher@kcl.ac.uk
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R. Uher et al.
369
370
R. Uher et al.
Nortriptylinetreated subjects
Week
Mean
S.D.
Mean
S.D.
0
6
8
12
26
25.28
25.05
25.33
25.33
24.72
4.65
4.76
4.57
4.60
4.01
384
286
334
302
134
26.15
26.23
26.26
26.47
26.83
5.27
4.68
4.83
5.02
5.02
246
179
211
168
61
Results
Sample characteristics
Of the 811 GENDEP participants, 630 (78 %) had BMI
measured both at baseline and at least one follow-up
visit and were included in the analyses. BMI
measurement was available on 25 occasions per individual (mean 3.6, median 4 occasions ; Table 1). The
included subjects did not dier from the remaining
181 participants on sex, age, depression severity or
BMI at baseline (all p>0.05). The sample included
235 men and 395 women with a mean age of 42.8
(s.d.=11.6, range 1972) yr, and a mean MADRS score
of 28.4 (s.d.=6.6, range 1447). A total of 384 participants were treated with escitalopram [192 (50 %) of
them randomly allocated] and 246 with nortriptyline
[157 (64 %) of them randomly allocated].
Body-weight changes during treatment
Table 1 shows observed values of BMI at each timepoint. However, since there are a number of missing
values at each time-point, the numbers do not represent the same groups of individuals. To enable
comparison across time-points, Fig. 1 shows the timecourse across the 26 wk with missing values replaced
by the best linear unbiased estimate from drug-specic
mixed regression models which included both linear
and quadratic eects of time.
Over the rst 12 wk treatment, participants treated
with nortriptyline gained on average 1.22 kg, increasing their BMI score by 0.44 (95 % CI 0.370.51,
p<0.0001). After 6 months of treatment with nortriptyline, the average weight gained reached 1.82 kg,
increasing the BMI score by 0.64. The weight gain affected a signicant proportion of nortriptyline-treated
individuals : after 6 months treatment 95 (38.6 %)
were estimated to gain o2 kg compared to only six
(2.4 %) estimated to lose o2 kg. A small proportion of
nortriptyline-treated individuals gained a substantial
amount of weight [15 (6.1 %) gained o5 kg ; only 2
(0.8 %) lost o5 kg].
The weight of escitalopram-treated participants
remained relatively stable, with a non-signicant
average increase of 0.14 kg, or 0.05 on the BMI (95 % CI
x0.001 to 0.10, p=0.0541). After 6 months treatment
with escitalopram, an average participant gained
0.34 kg, increasing their BMI score by 0.12. After 6
months treatment, 51 (13.3 %) escitalopram-treated
participants gained o2 kg and 29 (7.6 %) lost o2 kg.
Only a small number of escitalopram-treated individuals experienced major weight changes [eight
(2.1 %) gained and 10 (2.6 %) lost o5 kg].
The dierence in weight gain between the two
antidepressants after controlling for baseline BMI
was signicant [baseline adjusted dierential weight
increase of 1.16 kg, or BMI change of 0.40 (95 %
CI 0.270.53, p<0.0001) ; Fig. 1] and was further
strengthened in a sensitivity analysis restricted to
randomly allocated participants [baseline adjusted
dierential weight increase of 1.48 kg or BMI change
0.51 (95 % CI 0.330.69, p<0.0001)]. The weight gain
did not dier signicantly by sex or smoking status
and two-way interactions of sex and smoking with
drug were non-signicant (all p>0.05).
The relationship between changes in depression
severity and changes in BMI diered by drug, reected by a signicant interaction between drug and
BMI in their eects on observed mood (p<0.0001),
which remained signicant in a sensitivity analysis
restricted to randomly allocated participants (p<
0.0001). This was due to a strong negative correlation
between the change in BMI and change in depression
severity among those treated with nortriptyline (r=
0.22, p=0.0007) but no signicant relationship between change in BMI and change in depression
severity among those treated with escitalopram
(r=0.06, p=0.2275).
Body-weight changes by weight category
The weight gain during antidepressant treatment was
unequally distributed across weight categories and
treatment arms, with a signicant interaction between
baseline BMI and drug (p=0.048). The interaction was
conrmed in a sensitivity analysis restricted to randomly allocated participants (p=0.10 due to smaller
371
0.7
Nortriptyline
0.6
BMI change
0.5
0.4
0.3
0.2
0.1
Escitalopram
0
0.1
0
12
Treatment week
26
Fig. 1. Time-course of body mass index (BMI) change over 26 wk treatment by antidepressant. The y-axis represents mean
BMI change with missing values at each time-point substituted with the best linear unbiased estimate adjusted for baseline
dierences in BMI. Error bars represent 1 standard error.
sample size). Among escitalopram-treated participants, a small weight gain was limited to those whose
weight was in the normal range at baseline (BMI
change 0.14, 95 % CI 0.070.21, p<0.001 ; Fig. 2 a).
Among nortriptyline-treated participants, those who
were underweight gained the most weight, followed
by normal weight and overweight individuals. Those
who were obese at baseline tended to lose weight with
both antidepressants (Fig 2 a).
Weight change as a symptom of depression
In order to dierentiate between resolution of depressive symptoms and unintended eects of antidepressants, we explored the weight changes during
treatment in relation to symptoms of weight loss and
weight gain reported at baseline. In total, 290 (46.0 %)
participants reported weight loss and 80 (12.7 %)
reported weight gain as a symptom of depression at
the baseline assessment. Weight change during treatment with either escitalopram or nortriptyline was
unrelated to these baseline symptoms and there was
no signicant drug x symptom interaction (all p>0.1 ;
Fig. 2b).
Weight changes as adverse eects of antidepressants
Figure 2 c shows that subjective reports of weight gain
and weight loss as adverse eects of antidepressants
accurately reected actual measured weight changes.
Among nortriptyline-treated participants, 127 (51.6 %)
reported undesired weight gain linked to the use of
nortriptyline and these individuals gained on average
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R. Uher et al.
BMI change
Over Obese
Under Norm
Escitalopram
Over Obese
Nortriptyline
BMI change
None
Gain
Loss
Escitalopram
None
Gain
Nortriptyline
BMI change
None
Escitalopram
Gain
Loss
None
Gain
Nortriptyline
Fig. 2. Body mass index (BMI) change over 12 wk of treatment with escitalopram or nortriptyline by : (a) baseline weight
category (x-axis : Under, underweight ; Norm, weight within normal range ; Over, overweight). (b) Depression symptoms of
weight-loss/gain reported at baseline (x-axis : Loss, weight loss reported as a symptom of depression at baseline ; None,
neither weight loss nor weight gain reported as symptom of depression at baseline ; Gain, weight gain reported as symptom
of depression at baseline). (c) Reports of weight gain or weight loss as adverse eects linked to antidepressants (x-axis :
Loss, weight loss reported as an adverse eect linked to the antidepressant ; None, neither weight loss nor weight gain
reported as an adverse eect linked to the antidepressant ; Gain, an adverse eect linked to the antidepressant). The y-axes
represent the best linear unbiased estimate of BMI change over 12 wk, adjusted for baseline dierences in BMI. Error bars
represent 1 standard error.
Discussion
In GENDEP, nortriptyline was associated with a signicant increase in weight in a large proportion of
men and women treated with this antidepressant.
The weight gain continued throughout the 6-month
observation period. Nortriptyline-related weight gain
was disproportionately larger in individuals with low
initial body weight, but could not be explained as a
restoration of premorbid body weight as it occurred
irrespective of whether weight loss was a feature of
the current depressive episode. Less weight change
373
374
R. Uher et al.
Acknowledgements
The GENDEP project was funded by the European
Commission Framework 6 grant, EC Contract Ref. :
LSHB-CT-2003-503428. Lundbeck provided nortriptyline and escitalopram for the GENDEP study.
GlaxoSmithKline and the UK National Institute for
Health Research of the Department of Health contributed to the funding of the sample collection at the
Institute of Psychiatry, London. The sponsors had no
role in the design and conduct of the study, or in data
collection, analysis, interpretation or writing of the
report.
We especially acknowledge the contribution of
Andrej Marusic and Jorge Perez, who were the principal investigators at Ljubljana, Slovenia, and at
Brescia, Italy, and who both passed away during the
conduct of the study. We also acknowledge the contribution of the following collaborators : Amanda
Elkin, Bhanu Gupta, Cerisse Gunasinghe, Desmond
Campbell, Richard J Williamson, Helen Dean, Maja
Bajs, Mara Barreto, Thomas Schulze, Christine Schmal,
Susanne Hofels, Anna Schuhmacher, Ute Pfeier,
Sandra Weber, Anne Schinkel Stamp, Alenka Tancic,
Jerneja Sveticic, Zrnka Kovacic, Pawe Kapelski, Maria
Skibinska, Aleksandra Rajewska, Anna LeszczynskaRodziewicz, Elzbieta Cegielska, Caterina Giovannini,
Cristian Bonvicini, and Luciana Rillosi.
Statement of Interest
Henigsberg and Kalember have participated in clinical
trials sponsored by pharmaceutical companies including GlaxoSmithKline and Lundbeck. Henigsberg
has received honoraria for participating on expert
panels from pharmaceutical companies including
Lundbeck. Souery is a member of a national advisory
boards for AstraZeneca, BristolMyers Squibb, Eli
Lilly and Lundbeck. Aitchison, Farmer and McGun
and have received consultancy fees and honoraria for
participating on expert panels from pharmaceutical
companies including Lundbeck and GlaxoSmithKline.
References
lvarez-Jimenez M, Hetrick SE, Gonzalez-Blanch C,
A
Gleeson JF, et al. (2008). Non-pharmacological
management of antipsychotic-induced weight gain :
systematic review and meta-analysis of randomised
controlled trials. British Journal of Psychiatry 193, 101107.
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