Clinical Depression In Adults. Depression SSRI vs Tricyclics ?
Q.Is the selective serotonin reuptake inhibitor fluoxetine more effective or more costly than the tricyclic antidepressants desipramine and imipramine in the treatment of depression in primary care?
A.The study design is a randomized, unblinded trial of usual care with either fluoxetine, desipramine, or imipramine. The patients' physicians controlled all aspects of the therapy, including starting dose, follow-up visits, medication adjustments or changes and referrals. Patient status was evaluated after 1, 3 and 6 months of therapy. Statistical analysis was by intention to treat. This study design closely mimics the clinical use of antidepressants by family physicians. The major weakness in the design is the inattention to the role of psychotherapy in these patients. The patients received substantial amounts of therapy, but the report gives very little attention to the type and intensity of therapy, and its effect was not evaluated in the analysis. At 1, 3 and 6 months, there was no clinically or statistically significant difference in any of the clinical outcomes: about half of the patients on each drug achieved clinical remission. Relatively few patients continued medication at the minimum effective dose cited by the recent AHCPR guidelines,1 although significantly more patients with fluoxetine (61%) met this criterion than desipramine (49%) or imipramine (48%). The average dose of either TCA was only about 100 mg. Significantly fewer patients taking fluoxetine discontinued it because of adverse effects before one month-9% vs 27% (desipramine) or 28% (imipramine) (p = 0.001). Total cost between the three drugs were similar: the higher drug cost of fluoxetine therapy - approximately $100 more for six months of therapy -was balanced by charges for more frequent hospitalizations and office visits by patients receiving a TCA. between among fluoxetine, desipramine, and imipramine when used for mild to moderate depression in adults diagnosed by family physicians. This report also shows that the total cost of care for patients receiving fluoxetine is comparable to those given the other medications. However, cost calculations may be different in other settings. The findings about side-effects confirm the usual clinical wisdom about SSRIs, but the increased incidence of side effects in the TCA treated patients did not affect quality of life scores. Why have SSRIs become so popular, both with physicians and patients? The answer is not due to efficacy, but rather a combination of side effect profile, pharmaceutical marketing, and the popular culture. A major influence may be the current fashion of the SSRI agents. Cued by countless glowing reports in the popular press, our patients know about these medicines and come asking for them. This popularity will improve their placebo power and minimize the discomfort of side-effects, at least for a few years.
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