Jan. 29, 2009 -- When someone swallows his or her first antidepressant, it may come as a surprise how the psychiatrist chose that particular pill to prescribe: It's a best guess out of dozens of antidepressants on the market.
Now, a few psychiatrists have set out to bring some order to this educated guessing game. By looking at 117 studies of the 12 most popular antidepressants, researchers ranked the top 12 drugs in the journal The Lancet.
To view their results, click here.
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.
"We were surprised because we found a difference among antidepressants," said Dr. Andrea Cipriani of the University of Verona, Italy, and a co-author on the study.
"What we usually said was that all antidepressants worked the same," said Cipriani, who explained that doctors often compare different side effects while choosing an antidepressant.
"So, is there a rationale, is there a hierarchy?" Cipriani asked.
Now, he hopes the ranking will offer more guidance for doctors choosing the first antidepressant for a patient.
Although many psychiatrists are leery of the list, patients who've gone through years of distressing trial and error might find it comforting.
"When I first was diagnosed with depression, they tried all sorts of medication," said Paul Letourneau, 67. "It was terrible."
Letourneau of Worcester, Mass., lived antidepressant-free until 2004, when his parents died, his dog died and he lost his house. Then his life-long mild depression took a serious turn. Drug after drug, Letourneau found the side effects worse than the depression itself.
His rollercoaster emotions landed Letourneau in the hospital on suicide watch four times in two years.
"I was really over-medicated and he [his current doctor] ended up taking me off a lot of the medication and we settled on the two that I take now, and I feel great," Letourneau said. "I've been stable for a year.
"When your medication starts to work and you get involved in a positive thing in life, it does help you tremendously," he said.
Cipriani said issues like Letourneau's motivated him to try and narrow down the best drugs for a patient in need of antidepressants to try the first time. Indeed, Cipriani added, the idea and the method for ranking treatments is not new in medicine.
The Practice of Ranking Medicine
"This has been used in oncology [cancer treatment] but this is the first time it's been used in psychiatry," he said.
Yet, the ranking did little to sway the thinking of some psychiatrists.
"This rating would not change the way that I prescribe at all," said Dr. Mark I. Levy, a distinguished life fellow of the American Psychiatric Association and an assistant clinical professor of psychiatry at the University of California, San Francisco.
Levy said he largely agrees with the rating because he has found that, on average, Zoloft and Lexapro come with fewer side effects, such as agitation, insomnia or weight gain.
"However, 'on average' doesn't take into account the individual patient who is sitting in front of me in my office," Levy said.
When patients come to Levy, he tries to match their unique emotional profile to the drug with the most compatible side effects, he said.
"For example, an agitation patient with severe insomnia may do best on Paxil, not Zoloft ... a patient with marked symptoms of psychomotor retardation may do best on Prozac. A patient with great concern about their libido may do best starting on Wellbutrin," Levy said.
But, in many cases, the first person to prescribe an antidepressant isn't a psychiatrist, it's a family physician. In that case, Levy might see use for such a ranking.
"It may greatly affect prescribing practices by non-psychiatric physicians, primary-care doctors in particular, who do most of the antidepressant prescribing, so it is good news for the generic makers of sertraline and for Forest Pharmaceuticals, who still have the patent on Lexapro," Levy said.
Other psychiatrists believed the rankings reflected their usual prescription decisions for patients trying antidepressants for the first time, anyway.
Trying Antidepressant No. 2
"I would be likely to start patients on either Zoloft [because it's cheaper] or Lexapro ...," said Dr. Harold G. Koenig, a professor of psychiatry and behavioral sciences at Duke University Medical Center in Durham, N.C.
"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.
Still, Cipriani hopes the rankings will have an impact on depression treatment, even if psychiatrists use other ways to choose an antidepressant for their patients.
He hopes the ranking could be used as a measuring stick for all the new antidepressants coming to the market.
"When developing new drugs for treating depression, usually we have placebo controlled trials ... but before new treatments that are going to be on the market, we need an active comparable list," Cipriani said. "Perhaps the new drugs have to be better than the active standard."
As for Letourneau, he thinks beating depression requires the right drugs, but also a change in thinking.
"When people suffer from mental illness, they very often isolate themselves in life," Letourneau said. "The best thing is to get active. When you sit on your butt doing nothing, all you do is think about your problems.
"I volunteer every day in a place called the Genesis Club in Worcester, Mass," Letourneau said. "I feel great."