During a recent chat with a physician, he told me that since all SSRI anti-depressants “basically have the same properties/effects,” he generally prescribes whichever SSRI is the least costly for the patient. (SSRI stands for selective serotonin-re-uptake inhibitor. whatever.)
I thought research showed that some anti-depressants work better than others. (Of course, some research shows placebos work better than anti-depressants. Go figure.)
What’s the straight dope?
The physician who said that is mistaken. There’s a great deal of individual variation, and selection should be based on patient’s symptoms matching the medication’s effects and side-effects. Even then, there is some trial and error involved, to see which one meshes with the patient’s neurochemistry best.
The “SSRI = placebo” study is small, and not constructed to really answer the question as to whether their effectiveness is the same. There is no doubt in my mind that SSRI’s are far more effective than placebo. They’re just not the miracle drugs for everyone that some have claimed they are.
QtM, MD
IMHO, that physician deserves a pat on the back for considering cost when in the “trial and error” phase of treatment.
I doubt you’d find such a pragmatic and sensible attitude common among physicians and psychiatrists these days, for a variety of reasons.
Our country’s drug industry spending billions every year to insure that patients know what drugs they want to take before they even get to the doctor’s office is probably one of them.
The drug industry’s marketing efforts are, of course not limited to the patient side. There are literally hundreds of “door to door salesmen” that canvas the country talking up any doctor or medical proffesional who will listen about their company’s newest wonder drug.
A large portion of Americans would prefer to take the most expensive drug option available whenever possible, even foresaking generics for the “name brand” of inexpensively manufactured simple compounds that have been produced for literally decades- because “their insurance pays for it.”
There are at least 14 types of serotonin receptors. There are probably more that we don’t know about yet. Your doctor doesn’t know much about it.
Each drug acts on different parts of the brain (and other parts of the body). Futhermore, each individual’s brain is different due to early development (this is fundamental developmental neurobiology, by the way).
Moods are influenced not just by serotonin, but also by dopamine, noradrenaline, oxytocin, testosterone, estrogen, thyroid hormones, cytokines, blood sugar levels, acetylcholine, presynaptic structures, postsynaptic structures, and so on.
Different SSRI’s can affect any number of these directly, or through indirect chemical pathways.
Sigh. Your experience is typical of doctors who are fundamentally ignorant about the brain, and who believe the simplistic marketing materials of the pharmaceutical companies.
Well, there may be 14 types of serotonin receptors, but among commonly prescribed SSRI’s, there is little if any clinical difference (at least for treatment of depression). So, why not go for the cheapest initially and then, as Qadgop says, change SSRI’s as necessary according to the patient’s response or lack thereof.
Damn if I can find it, but we had an article in Journal Club a few months ago from a big study comparing effectiveness and side effects of what I consider to be the “Big 3” SSRIs–Prozac, Zoloft, and Paxil. It found no differences, on the whole, among the three in terms of efficacy or side effects. (There may have been one category that crept up to statistical significance, but I’m not sure. Like I said, I can’t find it.) Most docs have their beliefs about what SSRIs have what side effects–I have mine–but there isn’t really evidence to back that up.
A quick look at Medline shows me a couple more studies saying the same thing.
Now, my experience (and that of most people) is that while there are no consistently different side effects, different people will react differently, and it’s impossible to predict who will respond most effectively to what and with which side effects. Thus, to me, it makes perfect sense to start with the cheapest SSRI. This is what I usually do–I’ve become fond of generic fluoxetine (Prozac), which is less than half the price of the others. (A lot of my patients can’t even afford the $30/month fluoxetine, and for them I use whatever we have in the sample cabinet until we can set them up with the company’s indigent program.)
Looks like KarlGauss beat me to the punch, but that is the article I was talking about.
Dr. J
Low cost is a good thing. But has nothing to do with the statement that all SSRI’s are the same.
I’ve read the abstract that you cited, and many other studies which are equally flawed in the original journals. The issue is individual differences, which this study ignored. An individual can respond very differently to fluoxetine and sertraline. Another individual can respond in opposite ways. Big studies ignore these differences.
Among the flaws of this study: it used no placebo group. There could be very little drug effect at all. In fact, by the end of the study, 21% of patients didn’t participate. Why? As is typical with such studies, the drug is found to be “effective and well-tolerated”, though many people have the opposite experience.
They used 573 patients. This allows the researchers to average so many individual reactions together that the result is meaningless for any individual. Typically 30% of patients in such trials get no effect or drop out due to side effects. Why is there such a difference between the patients who respond well, and those who don’t respond or have severe side effects? They don’t know, and don’t study this question.
I notice that the abstract says “Primary care physicians were allowed to switch patients to a different SSRI or non-SSRI antidepressant if they did not adequately respond to or tolerate the initial SSRI.”
If all SSRIs are the same and equally effective, why would switching medications be necessary? How often was this done? When? Are these patients who switched medications included in the final results? We don’t know, so the numbers are meaningless.
I repeat, I agree that starting with a low cost medication is a good idea. But it certainly does not mean that all SSRIs will have the same effects for Country Squire.
My point, and that of the cited article, is that unless and until you have reason to believe that a particular patient responds better (or worse) to a particular SSRI, there’s no clinical reason to start with any one SSRI.
I should have added that I don’t view the absence of a placebo group as a flaw. The investigators were not trying to determine if SSRI’s were more effective than placebo. They were looking to see if one SSRI was better than another.
the responses from MDs are encouraging. Imagine how much could be saved if every physician in America started with the least expensive medically appropriate solution, including prescribing nothing at all.
They don’t ignore them–they just make no commentary on them. That’s not the question they’re trying to answer.
Yes, we do know. They were included in the results, based on which drug they were initially started on. That’s what they mean by “intention-to-treat analysis”.
Do you believe that there is some way to tell which SSRI is going to work best in a particular patient? If so, what is it? If not, do you agree that it doesn’t matter which one you start them on first?
Dr. J
I agree with Frantic mad on this point. You don’t swap a subject between experimental groups mid-way through a drug comparison study and include that subject in the final analysis.
That is simply illogical.
You do if it’s an intention-to-treat analysis.
Studies are usually set up to answer a fairly specific question, or to study a particular decision point. In this study, the question was something like, “If a patient presents to my office with this particular set of symptoms, does it matter, on the whole, which of these drugs I start at that point?” You may eventually have to change the drug, but that’s a different decision point–it doesn’t change the decision you made before, and you want to study the results of that particular decision.
IIRC, all three drugs had similar rates of patients being switched to other drugs.
Dr. J
Anecdotal info: a good friend of mine is a psychiatrist. She finds that taking a good family history can be a big determinant in which SSRI she prescribes. For reasons she can’t explain, she’s found whole family bunches who tend to respond better to the same SSRI. So if Ms. X comes in and needs an SSRI, and happens to be the sister of Ms. Y who did quite well on luvox, but not so hot on Effexor or Prozan, Ms. X may get started on luvox first.
Hmmm. “Making no commentary” seems a lot like ignoring the question to me.
A fundamental problem with these studies is that they do not adequately study side effect profiles and individual differences. Consequently, the reader gets the impression from studies such as the one you cited that these medications are all the same for everyone.
No, I don’t agree for a number of reasons, though I do agree that the science is very inexact on this point. But Country Squire’s doctor said that all SSRIs have the same properties and effects, and it is that simplistic attitude that I am disputing.
I don’t think this question has been definitively answered.
“All anti-depressants are basically the same” is clearly false. There is a big difference between MAOIs, TCAs, SSRIs (and probably SNRIs), etc.
“All SSRIs are basically the same” is something I have long suspected to be true. I always start with fluoxetine, which is genericized in Canada and has the advantage of a longer half-life (hence theoretically could be dosed less often).
The drug companies view is the long half-life of Prozac is a disadvantage. The makers of Paxil claim this drug has the strong indications (compared to other SSRIs) against anxiety and social phobia, disorders very often linked to depression. I still usually start with fluoxetine when I prescribe an anti-depressant.
Many doctors routinely include cost in their appraisal of which drug to prescribe. No point prescribing a drug if the patient doesn’t take it, or can’t afford it. Many doctors routinely do not prescribe medications to patients. I have seen some doctors, OTOH, who prescribe very expensive blood pressure medications to patients who genuinely can’t afford them when dirt cheap thiazide would have been a far better choice.
Once again, that is not what I (or most people) think at all. Of course they are not all the same for everyone. In the aggregate, however, there are not any consistent differences among them, so one cannot predict how someone will react (aside from family history, as QtheM mentioned–I’ve heard this and I do this as well, although I’m not sure if there are data to back it up).
Then how should one pick an SSRI to start with?
Hopefully they won’t be now that the results of the ALLHAT study are out. That was a great victory for cost-effective medicine–the best medicine to start hypertensive patients on turned out to also be the cheapest one.
This thread will ultimately resolve around the meanig of “basic”. Side effects profiles for SSRIs are similar, but personally I have seen higher side effects with Paxil than Zoloft or Prozac. No one disputes the complexity of brain biochemistry, and we do not yet know how different these SSRIs are, even in terms of brain chemistry. When I say they are basically similar, I personally mean that although they would give slightly different clinical responses if given to the same patient, I cannot predict this in advance without other information. Hence it makes sense to start with a proven, cheap drug with a reasonable expectation this may be the one.
I thought the same thing. But I took a non SSRI – Tofrinal (sp?) for Anxiety Attacks and it worked within’ a day or so.
12 years later I had them again so my doctor suggested Prozac. NOTHING. It did NOTHING. No matter how the does was. I could tell the drug worked as it did influence the amount of dreams and the vividness of them (that wears off)
A few years later they came back again when I had to fly. My doctor gave me PAXIL. It worked with in a day and NO side effects, no anxiety attacks.
I believe it is correct to say chemically they are similar but they all don’t effect everyone the same.
For instance for me I take Tylenol if I have a cold. It works best (for me) for the body aches. But did nothing for my toothache. Ibruprofen works better than anything (asprin, aleve, orudis).
Aleve does NOTHING for me. It has never stopped any headache or anything for me.
So chemically drugs can be similar but they don’t work on everyone.
Cost is something to consider but remember that people on Anti-Depressants need help. Sometime serious.
I suffered with Anxiety for a year on Prozac. (my anxiety attacks come and go on their own) but in ONE day on Paxil it stopped and I even conquered my greatest fear – flying.
If I ever need an antibiotic I can take Penicillin. It is cheap I can get a prescription filled for $7.00 out of my pocket. My insurance makes me pay $15.00 for generics. So I ask could I take penicillin ( I had a couple of bad teeth that got infected) my dentist said no you should have this and he gave me keflex.
Unfortunately a lot of problems like depression, anxiety or even asthma take a while to play with the medicines to fine out what dose works.