Antidepressants: Which One Is Best?

Let's cut to the chase:  no single antidepressant is head & shoulders better than the rest.  Of course, this statement isn't going to make me welcomed by Big Pharma.  This isn't just my opinion but rather the conclusion of a systematic review & meta-analysis of 234 studies of 2nd generation antidepressants published this month in Annals of Internal Medicine.  In other words, the clinical effectiveness of this class of drugs is the same across the board - they all work in the treatment of major depression.

However, as noted in USA Today, due to differences in onset of action, adverse effects, and of course, out-of-pocket costs, one antidepressant may be better for a given individual but not his/her twin sibling.  The authors pointed out that it's reasonable to tailor antidepressant choice based upon (desired) side effect(s).  For someone complaining of insomnia, we should consider a more sedating medication.  For someone complaining of weight loss, we should consider an appetite stimulating medication.  For someone complaining of sexual dysfunction, we should consider one w/less adverse sexual effects.  And so on & so forth.  

In fact, these conclusions are quite similar (at least to this simple family physician) to those derived from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D), at least at first glance.  But as I dug into this large publicly funded study a bit further, it turns out that a reanalysis of STAR*D turned up some issues w/bias & statistics such that antidepressants are only "marginally efficacious" when compared to placebo in treating major depression.

If this is indeed the case, it would certainly explain the difficulty we have in finding the right medication for each individual.  More importantly, it raises the question of just how do we treat major depression?

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