Dean AJ, Bell J, Christie MJ, Mattick RP. Depressive symptoms during buprenorphine vs. methadone maintenance: findings from a randomised, controlled trial in opioid dependence. Eur Psychiatry. 2004 Dec;19(8):510-3
Dear Colleagues,
This well conducted double blind, randomised study examined psychiatric symptoms used the Beck Depression Inventory (BDI) in a subgroup of consenting patients seeking maintenance treatment for opioid dependence. There were 54 subjects who were each tested at entry and at 3 months into treatment. While we are not told the proportion who had depression, the mean BDI dropped from 22 (�10) to 12 (�10) in methadone patients and 25 (�11) to 13 (�9) in those on buprenorphine. By my calculations, the methadone patients saw a mean reduction of 48% in their severity while for buprenorphine, it dropped by 46%. We are told that the difference between the groups was not significant and that larger studies would be needed to determine if there is actually any difference. In my view, any residual difference would be modest, and other factors would probably prevail in clinical decisions about which drug to prescribe. While a BDI reading of 22 would only indicate a moderate depression individually, these are mean figures with standard deviation of 10 so there must have been a number of severely depressed subjects in each group.
The mean doses (for third month) were 48mg (� 20) for methadone and 9mg (� 4) for buprenorphine. Both would probably be considered lower than optimal although they are higher than in a number of other quoted reports.
Thus the conclusion should be that both methadone and buprenorphine treatments are associated with dramatic reductions in overall depression symptoms in the first three months of maintenance treatment. Some still warrant specific antidepressant treatment and indeed, one in ten had been prescribed such drugs during the study period. This is likely to improve retention and reduce illicit drug and/or alcohol use.
The authors state: "The reasons for improvement include both pharmacological and psychosocial stabilisation and may also reflect poorer retention rates for depressed subjects". This latter seems inconsistent with their finding that 'Baseline BDI scores ... were not predictive of treatment retention'.
It is always gratifying to have ones long-held clinical impressions confirmed by controlled scientific research. While the comparative findings may be novel, the observations about depression are not. Several relevant references are over 20 years old. We should all be reassured to learn that both methadone and buprenorphine treatments are probably equally effective in addressing symptoms of depression. This finding supports the general therapeutic practice (in countries where both drugs are available in normal practice) that methadone is the more common first line drug and buprenorphine is used very successfully for those who are unable or unwilling to take methadone. As with naltrexone (and probably any other drug), doctors who preferentially use buprenorphine will often find limited results with a proportion of patients, notably those with high tolerance, who may later transfer successfully to methadone or other treatments.
