Second-generation antidepressants are similarly effective in the treatment of major depression in adults, so drug selection should be driven by adverse event profile, cost, and patient preference, according to a clinical practice guideline issued by the American College of Physicians.
Basing their conclusions on evidence derived from 203 clinical studies involving selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and selective serotonin norepinephrine reuptake inhibitors (SSNRIs), the guideline authors wrote that “existing evidence does not justify the choice of any second-generation antidepressant over another on the basis of greater efficacy and effectiveness.”
They also determined that the efficacy and effectiveness of the various agents did not differ among subgroups based on age, sex, race, or ethnicity.
Because the various agents are associated with different adverse events, “physicians and patients should discuss adverse event profiles before selecting a medication,” the authors wrote (Ann. Intern. Med. 2008;149:725–33).
For example, although sexual dysfunction is a commonly reported adverse event associated with second-generation antidepressants, “bupropion is associated with a lower rate of sexual adverse events than fluoxetine or sertraline, whereas paroxetine has higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, or sertraline,” they stated. “In addition, SSRIs are associated with an increased risk for suicide attempts compared with placebo.”
The practice guideline also recommends that clinicians:
▸ Regularly assess patient status, therapeutic response, and adverse effects of antidepressant therapy beginning within 1–2 weeks of treatment initiation.
▸ Modify treatment if the patient does not have an adequate response within 6–8 weeks.
▸ Continue treatment for 4–9 months after a satisfactory response in patients with a first episode of major depressive disorder, and consider longer treatment after a satisfactory response in patients who have had two or more episodes of depression.
The authors stress the importance of monitoring patients for behavioral changes that could indicate a worsening of depression and note that the risk for suicide attempts is greater during the first 2 months of treatment than during other times. Additionally, they state that “one of the most important aspects of care is assessing the response to treatment and making necessary changes in therapy,” including adding other therapeutic modalities or alternate drugs.
Acknowledging that other treatment approaches, such as cognitive-behavioral therapy and psychotherapy, can be used in the management of depression, “the scope of this guideline is limited to pharmacotherapy with second-generation antidepressants,” the authors wrote.
The American College of Physicians' recommendations are in line with the current treatment guidelines of the American Psychiatric Association, according to Dr. James Jefferson of the University of Wisconsin, Madison. “In general, I agree with the [ACP] recommendations, although I am sure various pharmaceutical companies are going to be going over them with a fine-toothed comb,” he said in an interview. The focus on drug therapy alone is not inappropriate, he noted, stating that the authors “had a very specific goal.”