Clinician's Digest - Page 3

A metanalysis comparing the new antidepressants with previous antidepressants in the February 28 issue of the British medical journal The Lancet finds that the relatively older sertraline (Zoloft), with its highly favorable balance between efficacy, side effects, and cost, might be the best first choice for adults suffering from moderate to severe depression. The new generation escitalopram (Lexapro) also had a highly favorable rating on efficacy and side effects, but is significantly more expensive. Other newer antidepressants like duloxetine (Cymbalta), fluvoxamine (Luvox), and reboxetine (Vestra), in addition to the older paroxetine (Paxil) and venlafaxine (Effexor), had the highest rates of negative side effects.

A metanalysis of the new generation of atypical antipsychotic meds in the January 3 Lancet, led by German psychiatrist Stefan Leucht, finds that five of the nine atypicals studied were no better than the older antipsychotics in overall efficacy, and one, quetiapine (Seroquel), was less effective. Four—amisulpride (Solian), clozapine (Clozaril), olanzapine (Zyprexa), and risperidone (Risperdal)—were slightly to moderately more effective, but given their significantly higher costs, may not be the best choice for some patients.

What of the claim that the atypicals cause fewer side effects than the older antipsychotics? Although all atypicals seemed to cause less involuntary muscle action, restlessness, and physical rigidity, 95 of the 150 trials that showed this compared the newer drugs to haloperidol, the most potent of the older meds and, therefore, the one most likely to make the side effects of the atypicals seem mild by comparison. An editorial accompanying the metanalysis by Peter Tyrer, professor of community psychiatry at London's Imperial College, suggests that this kind of study design is purposely manipulated to make the side effects of the atypicals seem more benign. When Leucht's metanalysis looked at studies comparing atypicals' side effects to those of less potent older meds, only Clozaril, Zyprexa, and Risperdal fared better. And several of the atypicals, including the most effective, had one side effect the older antipsychotics don't: significant weight gain.

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