Antidepressant rankings: Zoloft and Lexapro considered best overall

A number of antidepressants were recently ranked in different surveys:

Zoloft and Lexapro came in first for a combination of effectiveness and fewer side effects, followed by Prozac (fluoxetine), Paxil (paroxetine), Cymbalta, and Luvox among others.

The first was efficacy — or how likely patients were to experience the desired effects of the drug.

Efficacy:

1. Remeron (Mirtazapine)
2. Lexapro (Escitalopram)
3. Effexor (Venlafaxine)
4. Zoloft (Sertraline)
5. Celexa (Citalopram)
6. Wellbutrin (Buproprion)
7. Paxil (Paroxetine)
8. Savella (Milnacipran)
9. Prozac (Fluoxetine)
10. Cymbalta (Duloxetine)
11. Luvox (Fluvoxamine)
12. Vestra (Reboxetine)

The second was acceptability — the likelihood that a patient would continue using a drug for the duration of the study (it is generally assumed that a high ratio of patients dropping out indicates the presence of undesirable side effects for a drug).

Acceptability:

1. Zoloft (Sertraline)
2. Lexapro (Escitalopram)
3. Wellbutrin (Buproprion)
4. Celexa (Citalopram)
5. Prozac (Fluoxetine)
6. Savella (Milnacipran)
7.
Remeron (Mirtazapine)
8. Effexor (Venlafaxine)
9. Paxil (Paroxetine)
10. Cymbalta (Duloxetine)
11. Luvox (Fluvoxamine)
12. Vestra (Reboxetine)

antidepressantsMy experience with Lexapro was a disaster and I’ve written about Zoloft’s connection with irritability and rage. Paxil’s side effects are especially rough (see Bob Fiddaman’s Seroxat page) while Effexor’s withdrawal effects proved to be significantly challgenging. Although Prozac offset Effexor’s withdrawal symptoms, it causes severe somnolence that can impair cognitive functioning. And last but not least, Cymbalta contributed to the unfortunate death of Traci Johnson who had no history of depression.

These drugs may be effective for many people but it’s still a guessing game. Dr. Mark I. Levy, quoted in ABC News’s article on the rankings, mentioned that while psychiatrists may not have much use for the rankings, he sees them as beneficial for primary care physicians. And Dr. Harold G. Koenig, a professor at Duke University Medical Center, adds:

“I would be likely to start patients on either Zoloft [because it’s cheaper] or Lexapro … Unfortunately, that is almost none of my patients. By the time they get to me [a psychiatrist], the primary-care doctors have tried Zoloft and other antidepressants, so my patient are not the “new to medication” kind of patients,” he said.

I won’t rehash my thoughts on PCPs prescribing antidepressants and other psych meds. You can read about them here.

Lexapro maintains status as first-line antidepressant therapy

Lexapro vs. Pristiq According to a Decision Resources (DR) press release, Lexapro (escitalopram), a SSRI, “retains leadership among first-line therapies in the treatment of major depression” despite the fact that physicians have increasingly moved toward the use of SNRIs, eg, Effexor (venlafaxine). However, the reason why SSRIs still retain their first-line status is due to

  • cost
  • efficacy
  • familiarity

SSRIs have been out on the market for much longer than SNRIs so it’s what physicians are more comfortable with. As far as I know, there currently aren’t any generic SNRIs in the U.S.

As a result, SNRIs are likely pricier.

DR’s survey of psychiatrists found that the majority believe SNRIs work better in treating clinical depression than SSRIs and about 44 percent believe they have fewer sexual side effects. PCPs were also included in this survey and it seems that the majority of them believed the opposite despite DR’s spin that a lot of PCPs are on board with psychiatrists. From personal experience, four SSRIs were prescribed to me before I was shifted to a SNRI.

In the up-and-coming SNRI department, DR forecasts a bright future for Pristiq (desvenlafaxine).

Physicians are expected to move patients from Effexor to Pristiq-a newly approved SNRI- over the next two years. … Pristiq will begin to replace Wyeth’s Effexor XR and Lilly’s Cymbalta, especially in
psychiatrists’ practices.

This is an interesting analysis from DR considering that psychiatrists, health insurers, and even some investors seem less than impressed with the slight advantages the “me-too” drug has over Effexor.

(logos from Forest Pharmaceuticals, Inc. and Wyeth)

Pristiq receives approval from FDA

PristiqMore than a year ago, I promised to keep tabs on Wyeth’s new (renamed, rather) drug Pristiq. So I’m living up to it.

On February 29, 2008, the FDA granted Wyeth approval to move forward with putting the drug out on the market.

Wyeth said the company planned a big sales effort to introduce the product to psychiatrists and primary care doctors.

There’s a problem with that sentence. I’ll give you a second to figure out what’s wrong with it. Haven’t got it yet?

Primary care doctors. PCP should not be in the business of prescribing or providing psych meds. I’ve gone on and on about it at length before, but I’ll mention it again. PCPs are trained to treat overall conditions that have no need of referral to specialists. Think about it this way: If your psychiatrist prescribed anti-inflammatory medication because you mentioned that you’ve been having problems with your foot, you’d be taken aback, right? If a dermatologist prescribed heartburn medication after a patient mentioned he’d been having heartburn trouble, that would seem almost illogical, wouldn’t it?

(Pristiq logo from Pristiq.com)

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PCPs Don't Know Jack From Zyprexa

Eli Lilly’s actions continue to be appalling.

LillyApart from trying to hide the fact that Zyprexa induces weight gain, diabetes, and hyperglycemia, they also had sales reps encourage primary care physicians to prescribe Zyprexa for patients who did not have schizophrenia or bipolar disorder (basically off-label usage).

It seems that Lilly told marketing reps to suggest Zyprexa for dementia in the elderly. Lilly denies this, of course, since olanzapine (Zyprexa’s generic name) is not approved for that kind of use since it increases the risk of death in seniors with psychosis associated with dementia. Lilly also attempted to market olanzapine to patients with mild bipolar disorder who suffer mainly from depression. (In actuality, Zyprexa is approved to treat those who suffer from mania.)

This issue with Eli Lilly delves into precisely why I am against PCPs prescribing psychiatric medicines. Primary care physicians don’t know enough about the various psychiatric conditions to prescribe the appropriate kind of medication. This type of prescription should be left to specialists like psychiatrists. PCPs should focus on the things they deal with on a daily basis that no one else can take care of: the common cold, the flu, annual physical, etc. It should be the job of the PCP to refer a patient to a psychiatrist should they present symptoms of mental illness (depression, schizophrenia, etc.). I have been burned by having a PCP prescribe antidepressants for me and as a result, attributed my horrible experience with drugs to that.

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