The certainty of evidence is down-graded due to indirectness.
A network meta-analysis (NMA) «Duan H, Zhu L, Li M, ym. Comparative efficacy and ...»1 was designed to compare the efficacy and acceptability of different SSRI antidepressants for the treatment of binge-eating disorder, BED in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were as follows: 1) patients with BED were diagnosed clearly according to the relevant diagnostic criteria of DSM-IV/DSM-5, regardless of gender and age; 2) studies were clinically randomized double-blind controlled trials of monotherapy; 3) patients in SSRI antidepressant groups would be given any kind of SSRI antidepressants, at the same time, patients in the other groups got placebo or other SSRI antidepressants; 4) the results of studies need to include at least one of the following efficacy or acceptability outcomes: the weekly frequency of binge-eating episodes, acceptability (the dropout rate measured by the proportion of patients who dropped out before the study was finished for all causes), Hamilton Rating Scale for Depression (HAMD) score and body weight (kg).
Exclusion criteria were as follows: 1) duplicate publications; 2) conference papers, letters, and reviews; 3) non-monotherapy studies, such as medication combined with psychotherapy or surgery; 4) studies without relevant outcome indicators; 5) studies with incomplete or incorrect data information.
Two reviewers searched four databases including PubMed, Embase, the Cochrane Library and Web of Science from the earliest record of the databases to July 2022. The detailed search strategy was as follows: ("Binge Eating Disorder" or "Binge-Eating Disorder") and ("Antidepressants" or "Antidepressant Drugs" or "Antidepressive Agents" or "Antidepressant Medication" or "Fluvoxamine" or "Sertraline" or "Fluoxetine" or "Escitalopram" or "Citalopram" or "Selective Serotonin Reuptake Inhibitor"). Quality assessment of chosen studies and extraction of data would be accomplished independently by two authors. Outcome data was exctracted at baseline and post-treatment, as reported in the paper. Two authors assessed bias independently. The primary outcomes were the changes in binge frequency (the weekly frequency of binge-eating episodes) and acceptability (the dropout rate measured by the proportion of patients who dropped out before the study was finished for all causes). The secondary outcomes were the mean changes in HAMD score (HAMD score) and weight (kg) from baseline to endpoint.
A total of 1619 studies were obtained, including Pubmed (n = 131), Embase (n = 1126), Cochrane (n = 72), and Web of Science (n = 290). 378 duplicates were removed. 1241 studies were screened, and we excluded 1174 irrelevant records by titles and abstracts. Subsequently, after searching and thoroughly evaluating 67 articles in the full text, 58 records were excluded. The reasons for the exclusion of 58 papers were as follows: conference abstract or systematic review (n = 32), without control study (n = 5), without relevant outcomes (n = 6), wrong study design (n = 5), wrong population (n = 7) and wrong kind of antidepressant (n = 3), 9 RCTs were included. The treatment duration of all included trials was between 6 and 24 weeks. 7 trials were comparisons between SSRI antidepressants and placebo, and 2 trials were direct comparisons between different SSRI antidepressants. Among them, the detailed treatments were as follows: placebo (7 trials), fluvoxamine (3 trials), sertraline (2 trials), fluoxetine (4 trials), escitalopram (1 trial), and citalopram (1 trial). There were 420 participants, the average age of the patients ranged from 25.1 to 44.3. The proportion of women was relatively large in both the treatment group and the control group.
Network diagrams were used to show direct comparisons between different interventions. Mean difference (MD) was used to construct network meta-analysis of continuous data and to estimate the associations of binge frequency, HAMD score and weight changes with interventions. Odds ratio (OR) was used to conduct network meta-analysis of binary data and to estimate the associations of acceptability and interventions. MD < 0 indicated it had a better efficacy in the intervention group. In the same way, OR < 1 indicated better acceptability in the intervention group. I2value was used to evaluate heterogeneity and if I2value exceeded 50 %, the degree of heterogeneity was considered to be high. When the degree of heterogeneity was high, random-effects model was used. The Surface Under the Cumulative Ranking (SUCRA) was used to reflect the probability order of different antidepressants to be Only one of included studies was high risk of bias because this study chose to conceal the detailed generation of random sequence. The most of included trials showed the risk of bias was low.
The result of NMA revealed a significant reduction in binge frequency in patients who received sertraline (MD −1.935, 95 % CI −3.89 to −0.01) and fluoxetine (MD −1.75, 95 % CI −3.77 to −0.02) compared with those who received placebo. Compared to the other three antidepressants, sertraline was proven to reduce binge frequency more effectively. To further understand the results, four antidepressants were ranked by SUCRA values and, a higher SUCRA value suggested a lower frequency of binge eating. The efficacy ranking in reducing binge frequency was sertraline, fluoxetine, citalopram, escitalopram. Both sertraline and fluoxetine were linked with a substantial reduction in binge frequency, compared to placebo. Fluoxetine was related with a substantial reduction in secondary outcome, depression (HAMD) score. In the SUCRA analysis, fluoxetine was linked to the second-biggest reduction in binge frequency and the highest reduction in HAMD score, in HAMD score, followed by escitalopram, citalopram and fluvoxamine. However, all SSRI antidepressants were ineffective in losing weight. As for acceptability, there was little difference in dropout rates between antidepressants and placebo.
Study quality: moderate. Network meta-analysis of nine randomized controlled trials. Original studies partly small and from the turn of the millennium.
Applicability: The results are highly applicable to the Finnish adult population. The majority of the participants of the included studies were women.
General comment: There aren't more recent randomized controlled trials available on antidepressants in binge-eating disorder. Update on the American Psychiatric Association's Eating Disorders 2023 Guideline «The American Psychiatric Association Practice Guid...»2 states that in the context of binge-eating disorder, no single antidepressant or class of antidepressants can be recommended over others, and the choice of medication is made in collaboration with the patient, taking into account tolerability, side effects, and potential other medication. However, due to the increased risk of seizures associated with bupropion, it is not recommended if the patient has or has had vomiting behavior.