Anti-Depressants Ranked Versus Other Anti-Depressants

A study came out in The Lancet the other day and I held off writing about it, waiting to see how the media would handle it. It was a very large meta study of anti-depressant trials where one anti-depressant was trialed against another anti-depressant. I don't have access to full text of Lancet studies, but from the abstract it's apparent that the authors didn't report how those anti-depressants performed versus placebo in all these trials--it's possible of course that none of these studies had placebo arms or that only some did and some of the drug v. drug trials are bound to be small since the whole meta study included 25,928 people in 117 trials. Anyway, I point this out because I am highly suspicious of studies of psych meds that don't include placebo arms, since I don't think you can learn much about the value of an individual med without controlling for the placebo effect. That's just me, of course. Feel free to have your own opinion.

Just so folks know, I've taken six of these drugs and I pretty much hated them all.

What's interesting is that none of the media coverage I saw mentioned the placebo matter, so you really have to wonder about global efficacy of the drugs. I've read loads of anti-depressant studies over the years and generally speaking you end up with a fairly sizeable placebo effect and an effect size for the drugs that runs from 12 percent to about 30 percent. But this study was about trying to help patients (I guess) and doctors sort out which of the 12 modern anti-depressants are best, compared with other drugs in their class. (The study didn't look at extended release version of Paxil and Wellbutrin.)

The big winners were Zoloft and Lexapro, based upon their efficacy versus other anti-depressants and their tolerability versus other anti-depressants. The final nod went to Zoloft due to its being generic and inexpensive. With one exception, the researchers who authored this study had deep ties to pharma companies (see the above-linked abstract for disclosures).

ABCnews.com kindly produced a list of the rankings:

Efficacy:

1. Remeron
2. Lexapro
3. Effexor
4. Zoloft
5. Celexa
6. Wellbutrin
7. Paxil
8. Savella
9. Prozac
10. Cymbalta
11. Luvox
12. Vestra

Tolerability:

1. Zoloft
2. Lexapro
3. Wellbutrin
4. Celexa
5. Prozac
6. Savella
7. Remeron
8. Effexor
9. Paxil
10. Cymbalta
11. Luvox
12. Vestra

Interestingly, I didn't catch any press coverage of this study that noted that Savella is not approved in the US as an anti-depressant, but was only recently approved as a fibromyalgia treatment in the US. As for Vestra, it is not approved for any use in the US and in fact in May 2007, the FDA shot down its maker's application for the US. Obviously the study was aimed at a global market, but for US media to not catch that it was ranking two drugs not available for depression in the US is very, very sloppy reporting (and makes me extra cranky that some of these folks are getting a journalism paycheck while I am not).

What also interests me is the implicit assumption in the study and the press coverage that someone diagnosed with depression is going to head straight for the meds. That's just arrogant.

It is amusing however to see how poorly Cymbalta performed on all measures. You've got to expect that, Eli Lilly being Eli Lilly, its maker will have its sales reps out in the field pronto to somehow try and defang the effects of this study.