New Antidepressant Guidelines: All Work the Same, But Some Pricier Than Others

November 17, 2008


By Ray Hainer

MONDAY, Nov. 17, 2008 ( — If you are feeling depressed and your physician says she knows just the medication to help you, don’t take her word for it.

There is no evidence to suggest that one antidepressant is more effective than another at making you feel better, according to new guidelines released Monday by the American College of Physicians (ACP). Cost and side effects do vary, however, and should play a role when choosing a medication.

The guidelines were based on an analysis—the largest of its kind to date—of more than 200 clinical trials of antidepressants that have flooded the market since the release of fluoxetine (Prozac) more than 20 years ago.

Antidepressants are among the most widely prescribed drugs in the United States and include selective serotonin-reuptake inhibitors (SSRIs) like fluoxetine, sertraline (Zoloft), and paroxetine (Paxil), as well as other drugs, such as bupropion (Wellbutrin) and citalopram (Celexa).

“The available evidence shows no clinical difference in the efficacy of these second-generation antidepressants,” says Amir Qaseem, MD, PhD, the lead author of the guidelines and a senior medical associate with the ACP. “Medication A is the same as Medication B. You can’t really say that one is better than the other.”

The most common side effects of each medication do vary significantly, however, as do the cost of the drugs.

Venlafaxine (also known by its brand name, Effexor) appears more likely to cause nausea than SSRIs, for instance, while paroxetine tends to result in more weight gain than other drugs. Doctors should forgo predicting which medication is most likely to work for any given patient, and should instead discuss the side effects that patients are able (and willing) to tolerate and what their budgets will allow, the guidelines say.

In addition to factoring in cost and side effects, the guidelines also recommend that doctors:

  • Change or modify treatment if a patient doesn’t respond within six to eight weeks.
  • Monitor patients regularly beginning one to two weeks after they start a drug, to make sure it’s working and to check for side effects. The U.S. Food and Drug Administration recommends close monitoring for suicidal thoughts and attempts, as the risk is higher in the first couple of months.
  • Treat first-time depression patients (those experiencing their first episode) for four to nine months after they respond to treatment. Patients who have had two or more bouts of depression may need longer treatment.

About 1 in 5 adults in the United States experience depression at some point in their lifetime, and the economic burden of such depressive disorders is $83 billion, according to the ACP.

Next: Some monthly medications cost $200 more than others

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