Antidepressants – Some May Be Better Than Others

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A recent analysis of 522 studies including over 116,000 adults with major depression identified 4 antidepressants as more effective and tolerable than 17 others. The 21 antidepressants, all available in the US, included tricyclics (amitriptyline, clomipramine), selective serotonin reuptake inhibitors (fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine), serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine, desvenlafaxine, milnacipran, levomilnacipran), and atypicals (mirtazapine, nefazodone, vilazodone, vortioxetine, bupropion, trazodone).

Most participants were women (62%; mean age 44 years) with moderate to severe depression (89%). Participants took manufacturer recommended doses for an average of 8 weeks. All antidepressants studied were more effective at improving symptoms of depression than placebo. The most effective antidepressants (= 50% improvement on depression evaluation scales) with the lowest dropout rates were escitalopram, mirtazapine, paroxetine, and sertraline. The least effective and worst tolerated were fluvoxamine and trazodone.

Antidepressants are one of the most frequently prescribed drug classes. With so many to choose from, these results provide a guide for initial therapy in uncomplicated depression (eg, non-psychotic, treatment-resistant, or bipolar).

• Cipriani A, et al. Lancet 2018; published online Feb 2018

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