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



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

Dr. Qaseem says the message that doctors should take away from the guidelines is, “Talk to your patients, and make them aware that these medications are all the same. Then, tell them that these medications have different side effects—some more serious than others—and that the costs will vary depending on their health plan.”

The new guidelines run counter to the conventional wisdom that prevails, even among some experts.

Dr. Qaseem and his colleagues, for instance, compared the effectiveness of second-generation antidepressants among several subgroups of patients, including men and women, the young and old, and people who experience symptoms of anxiety or insomnia in addition to depression. They found no significant differences in efficacy, even among these patients; it's a finding that some psychiatrists would dispute on the basis of their experience, according to Gregory Simon, MD, a psychiatrist and researcher at the Group Health Center for Health Studies, in Seattle.

“There is a lot of clinical lore out there. People who have anxiety symptoms, say, are supposed to do better with this kind of medicine than that kind of medicine,” says Dr. Simon. “But that lore has never been supported by research. There’s no good way to predict who will do better with which medicine.”

The cost implications of this fact are important to consider, according to Dr. Simon, especially since individuals are increasingly responsible for a greater share of their health-care costs.

Although the efficacy of antidepressants is very similar, the price is not. A monthly supply of duloxetine (Cymbalta)—a drug that is still patent protected—runs about $240, according to figures compiled by Consumer Reports; an equivalent supply of fluoxetine (Prozac) costs just $30 a month, on average.

Both patients and doctors tend to labor under the misconception that newer (and more expensive) medications must be better, says Dr. Simon, and patients are often skeptical when a doctor explains that he is prescribing the cheapest available medication. But, he adds, “I can say with 100% certainty: The more expensive one is no better.”

The guidelines were published this week in the journal Annals of Internal Medicine.

Related Links:

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