PsychoTropicalResearch, serotonin and serotonin syndrome research.
Antidepressants - Choices, general issues
Antidepressants - Choices, general issues
Date Created: 20/06/1999 Last Modified: 07/10/2002 Last Checked: 03/01/2003
Current evidence indicates that there probably are meaningful and significant differences in antidepressant effectiveness and side effects between antidepressant drugs.
Gillman's maxim No 3
All antidepressants are equal, but some are more equal than others.
(apologies to George Orwell).
The typical drug trial with 50 or so patients treated for 4-6 weeks can no longer be considered an adequate piece of evidence for effectiveness. To some extent 'meta-analysis' can redress the balance; but large trials extending for 6-12 months may be more satisfactory, especially if they use outcome measures other than the usual 50% improvement on a symptom rating scale.
The most important issue is that of good evidence for antidepressant efficacy; the possible toxicity of a drug in overdose is of secondary relevance in most clinical situations.
This is because depressive illness is what kills people, not the toxic effects of drugs. Extensive epidemiological data indicates that less than 10% of fatal suicides die from toxic effects of their prescribed antidepressant.
Effective antidepressants make people better and reduce the risk of death by suicide.
More effective antidepressant drugs; various lines of evidence suggests that amitriptyline, clomipramine and sertraline are more effective than the 'average'.
Less effective drugs probably include; moclobemide, citalopram, paroxetine, fluvoxamine, trimipramine, doxepin, dothiepin, trazodone, nefazodone and mianserin and its cousin 6-azamianserin marketed as mirtazapine (trade name 'Remeron").
Although the old monoamine oxidase inhibitors (MAOIs), tranylcypromine and phenelzine, are no longer advertised (how many young doctors do not know they even exist?) it is well to remember that they are not just very effective, but are the treatment of choice for some patients.
The therapeutic effectiveness of a number of new drugs for treating major depression is not yet satisfactorily established. For instance, a significant number of studies strongly suggest moclobemide is less effective than alternatives. Several well executed studies have been unable to demonstrate superior effectiveness of moclobemide over placebo.
See other notes for detailed analysis.
All text ©Dr Ken Gillman MRC Psych - PsychoTropical Research®
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