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Monday, January 5, 2009

'2nd generation' antidepressants in Annals

And more on depression....

Annals of Internal Medicine recently had a couple articles on '2nd generation' antidepressants. (2nd generation here means SSRIs and other/newer antidepressants that have emerged in the last couple decades.) The first is a clinical practice guideline on 2nd generation ADs, and the second is the metaanalysis looking at the comparative efficacy of 2nd gen ADs which is the basis of the practice guideline. These are good ones for the teaching file - compiles a large amount of the comparative research on newer ADs.

The overall finding is that the vast majority of the research data support the idea that all of these agents are similarly effective for treating depression (where they have been compared, they have nearly uniformly shown to have comparable efficacy). What I found most interesting was the comparison of other outcomes, some of which are of particular importance in our patient population: 1) apparently there have been several studies showing that mirtazapine has a faster onset of action (symptom alleviation) than SSRIs, although by 4 weeks this effect is no longer apparent, 2) there is no clear evidence that any newer AD is better/worse than any others regarding alleviating anxiety symptoms associated with depression (with the exception of venlafaxine likely being better than fluoxetine), 3) nausea and vomiting are the most common reason for discontinuation of ADs (in the trials) with venlafaxine probably having more N/V than other ADs, and 4) duloxetine appears to be no better than SSRIs (at least paroxetine) in the treatment of pain associated with major depressive disorder (which is not to say that it's no better for other types of pain).

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