The efficacy of selective serotonin re-uptake inhibitors in depression: a meta-analysis of studies against tricyclic antidepressants

Abstract

A meta-analysis of the efficacy of five selective serotonin re-uptake inhibitors (SSRIs) against non-selective and noradrenergic re-uptake inhibitors (mainly tricyclic antidepressants, TCAs) is presented. Fifty five double- blind studies were identified after excluding those multiply reported or with methodological problems likely to bias the outcome in favour of SSRIs. Standardised effect sizes and 95% confidence intervals were calculated based on the difference in the reduction in mean Hamilton depression rating scale (HDRS) scores for the two antidepressants. For studies not reporting standard deviations, the pooled variance from complete studies was used and a variance-weighted mean effect size calculated. There were no differences in efficacy between SSRIs and comparator antidepressants for SSRIs taken together or individually. If studies were classified into high and low depression scores based on a median split of initial HDRS scores, there was a slight advantage to TCAs in the high HDRS group. In addition, SSRIs were slightly less effective than TCAs in in-patients and against combined serotonin and noradrenaline re-uptake inhibitors (clomipramine and amitriptyline). These findings were accounted for by a clinically significant lower efficacy of paroxetine in these subgroups. In contrast, SSRIs as a group were marginally more effective than noradrenergic antidepressants, a finding accounted for by two studies with sertraline. Fluvoxamine was the only SSRI to have been tested adequately in in-patients, where it displayed equal efficacy to TCAs. This meta-analysis confirms that SSRIs and TCAs are in general equally effective, but suggests that paroxetine's efficacy in in-patients and against clomipramine and amitriptyline is not proven.

Elevated hypothalamic/midbrain serotonin (monoamine) transporter availability in depressive drug-naive children and adolescents

“…36 However, non suicidal depressive adults did not present changes in serotonin receptor binding in prefrontal cortex. 37 Specific SSRIagents are effective in the treatment of both depressive adults 38 and depressive adolescents. 39 Altered serotonergic function has been noted in depressive children, too.…”

Comparing the Effects of Antidepressants: Consensus Guidelines for Evaluating Quantitative Reviews of Antidepressant Efficacy

“…Premature attrition results in the loss of outcome data from as many as 30% (Anderson and Tomenson, 1994;Hotopf et al, 1997;Montgomery et al, 1994;Song et al, 1993) of the subjects enrolled in an RCT. There is also a tendency for differential attrition of subjects.…”

“…Perhaps the most influential example of meta-analyses in mood disorders research is the series by Anderson, Freemantle, and colleagues, which demonstrated that SSRIs are, as a class, comparably effective and significantly better tolerated than TCAs (Anderson, 1998(Anderson, , 2000Anderson and Tomenson, 1994;Song et al, 1993). They also allowed for the detection of differences in subgroup comparisons not apparent in qualitative reviews or single primary studies.…”

“…They also allowed for the detection of differences in subgroup comparisons not apparent in qualitative reviews or single primary studies. For example, despite the overall comparability of these antidepressant classes, when the subgroup of studies of hospitalized or severely depressed patients was examined, significant differences in favor of TCAs were found (Anderson, 1998;Anderson and Tomenson, 1994), which directly paralleled the distinction between the TCAs and MAOIs. Further analysis that evaluated separately studies that used dual-acting TCAs (clomipramine and amitriptyline) and those that used more selective TCAs (imipramine, desipramine, maprotiline) revealed that this effect derived largely from studies of two tertiary amine TCAs, clomipramine or amitriptyline (Anderson, 1998).…”

A comparative study on efficacy of amitriptyline and escitalopram in the treatment of depression

“…6,[10][11][12][13] Comparative clinical trials indicate that SSRIs are as effective as TCAs, but relative safety and better acceptability of SSRIs has been the reason to their clinical success over TCAs. [13][14][15][16][17][18] However, published data evaluating and comparing the efficacy of different ADs are lacking in Nepal. This study was designed to compare the efficacy of escitalopram, most selective SSRIs with amitriptyline, a reference standard drug in the treatment of depression.…”