“Patients are usually encouraged to
take the newest medication,” said lead author Andrea Cipriani, M.D., of
the University of Verona, in Italy. “But it’s better to have an old
treatment that has been proved with many patients and many years in the
market.”
The reviews suggest that sertraline — sold under the
brand name Zoloft since 1991— could be the best initial choice of
antidepressant in people with acute major depression. The generic
formulation produced the best balance of effectiveness, tolerability
and purchase price, the authors say.
Patients also did well on
one of the newest antidepressants, escitalopram (Lexapro), but it is
not yet available in lower-cost generic form. The authors note that
comprehensive economic studies are necessary to evaluate overall
cost-effectiveness of various treatments.
Cipriani said that
the review recommendations are for new episodes of depression. “If a
patient is taking another drug and doing well, we are not saying he has
to change.”
New
antidepressants might be no more effective than the best existing
drugs, according to two new systematic reviews that compared 12
commonly used medications.
“Patients are usually encouraged to
take the newest medication,” said lead author Andrea Cipriani, M.D., of
the University of Verona, in Italy. “But it’s better to have an old
treatment that has been proved with many patients and many years in the
market.”
The reviews suggest that sertraline — sold under the
brand name Zoloft since 1991— could be the best initial choice of
antidepressant in people with acute major depression. The generic
formulation produced the best balance of effectiveness, tolerability
and purchase price, the authors say.
Patients also did well on
one of the newest antidepressants, escitalopram (Lexapro), but it is
not yet available in lower-cost generic form. The authors note that
comprehensive economic studies are necessary to evaluate overall
cost-effectiveness of various treatments.
Cipriani said that
the review recommendations are for new episodes of depression. “If a
patient is taking another drug and doing well, we are not saying he has
to change.”
The reviews appear in the most recent issue of The
Cochrane Library, a publication of The Cochrane Collaboration, an
international organization that evaluates medical research. Systematic
reviews draw evidence-based conclusions about medical practice after
considering both the content and quality of existing medical trials on
a topic.
Depression is the fourth-leading cause of disease
burden worldwide and antidepressant drugs are now the mainstay of
treatment for moderate to severe cases.
The aim of the two
reviews was to compare the benefits and side effects of sertraline and
escitalopram, respectively, with those of other antidepressants during
the first six to 12 weeks of treatment.
Cipriani noted that all
of the included studies compared one drug against another — not to a
placebo — so the results reveal not the absolute effect, but rather the
relative advantages and disadvantages of various medications.
In
addition, these reviews rely on summary data from each study, rather
than individual patient data. Future studies that go into greater
detail can help identify the best medications for various subgroups of
patients such as men vs. women, teens vs. adults and so on.
For
sertraline, the reviewers included 59 randomized controlled trials
totaling about 10,000 participants. Sertraline proved more effective
than fluoxetine (Prozac), but less effective than mirtazapine
(Remeron). In terms of side effects, bupropion (Wellbutrin) was easier
to tolerate than sertraline, while the latter outscored amitriptyline
(Elavil), imipramine (Tofranil), paroxetine (Paxil) and mirtazapine
(Remeron).
For escitalopram, the reviewers included 22
randomized controlled trials totaling about 4,000 participants. Few
statistically significant differences appeared in this review, although
escitalopram was more effective than citalopram (Celexa) and fluoxetine
(Prozac) and had fewer side effects than duloxetine (Cymbalta). The
drug manufacturer sponsored most of the studies in this review, so
there may be biases in favor of escitalopram.
Rather than
seeking genuine advances in treatment, the review authors say, some
pharmaceutical companies seem to be introducing close chemical cousins
of generic medications. By gaining patent protection for the “new”
drug, a company can market it as a higher-priced brand name product.
Sponsorship
bias is a recurring concern in trials of virtually all new medications.
In the Cochrane reviews themselves, one of the co-authors has received
research funds and speaking fees from the companies Asahi Kasei,
Astellas, Dai-Nippon Sumitomo, Eisai, Eli Lilly, GlaxoSmithKline,
Janssen, Kyowa Hakko, Meiji, Nikken Kagaku, Organon, Otsuka, Pfizer and
Yoshitomi. The Japanese Ministry of Education, Science and Technology,
and the Japanese Ministry of Health, Labour and Welfare have also
funded some of his research.
However, the co-authors of these
Cochrane reviews also published a recent study in The Lancet that was
free of any potential funding bias. The study also used a more complex
statistical method to analyze data from 117 randomized controlled
trials involving 25,928 participants.
The findings support the Cochrane reviews, Cipriani said, with sertraline and escitalopram ranking as the best treatments.
“Such
findings have enormous implications,” said Sagar Parikh, M.D., of the
University of Toronto, in a commentary published along with The Lancet
study. “For the clinician, prudent engagement of the patient in
treatment ideally involves giving the patient a choice.… A new gold
standard of reliable information has been compiled for patients to
review.”
In early studies, new medical treatments are typically
compared to sham treatments. Once the effectiveness of certain
approaches is well established, new options must be judged against the
best existing treatments.
Cipriani argued that this time has
come for antidepressants, and that sertraline is the drug to beat. “We
need new treatments in psychiatry, but they have to be proved better
than other treatments,” he said. “We should be comparing new drugs to
the best available existing drugs.”
Source:
FOR MORE INFORMATION
Health Behavior News Service: hbns-editor@cfah.org or (202) 387-2829.
The
Cochrane Collaboration is an international nonprofit, independent
organization that produces and disseminates systematic reviews of
health care interventions and promotes the search for evidence in the
form of clinical trials and other studies of interventions. Visit
http://www.cochrane.org for more information.
Cipriani A, La
Ferla, et al. Setraline versus other antidepressive agents for
depression. The Cochrane Database of Systematic Reviews 2009, Issue 2.
Cipriani
A, Santilli C, et al. Escitalopram versus other antidepressive agents
for depression. The Cochrane Database of Systematic Reviews 2009, Issue
2.
Supporting Documents
| Setraline versus other antidepressive agents for depression. |
| Escitalopram versus other antidepressive agents for depression. |