Monday, February 16, 2009

The SSRI Horse Race-- Take Our (Meaningless) Polls

This is not science, I'm just playing here, nothing random, nothing controlled, just questions for our readers.

I just read Peter Kramer's
Psychology Today blog post called Lexapro and Zoloft in a Cloud of Dust. Dr. Kramer talks about the relative efficacy of SSRI's, their market share, and if the drug company's influence docs to prescribe in a way that isn't in sync with research. Lexapro, the most expensive SSRI, apparently has the biggest market with 13% of the market share. He writes:
Now comes news of a large-scale analysis of research on antidepressant efficacy. Published in The Lancet, it finds a hierarchy, with Remeron, Zoloft, Effexor, and, yes, Lexapro, leading the pack, Cymbalta and Prozac in the middle, and Luvox, Paxil, and (especially) reboxetine, which is marketed outside the US, bringing up the rear. Celexa and Wellbutrin gave statistically fuzzy efficacy results; the two drugs appeared to be about average for the group. In terms of tolerability, Zoloft, Lexapro, Celexa, and Wellbutrin led the pack. So the results give a special place to Zoloft and Lexapro.

Do read the original post.

So I thought I'd put up two polls, and again, this isn't science, it's just curiosity. Pretend you didn't read the paragraph above, and I'd like you to answer two questions: What do you think is the most Effective SSRI, and Which SSRI do you think causes the most side effects. I don't care if you're the patient or the doctor, or a non-MD therapist who's simply just heard patients talk about the meds. It's a question of perception, with the awareness that maybe you haven't seen all the horses race. Efficacy: Which med works the best (If you've only been on Prozac and that worked great, it's fine to answer that!). Side Effects: Which med makes people feel the yuckiest (now there's a scientific term).


Anonymous said...

I have been tried on every one of the listed medications at various stages of my treatment. My experiences of efficacy and side effects are obviously my own, but I voted for Celexa and Luvox respectively.

Luvox was a dog...and Effexor, a close second.

Awake and Dreaming said...

effexor is the most amazing thing ever... until i forget a pill...

Anonymous said...

Just a suggestion - it might be a good idea to put the generic names there as well, as people might know their drugs by their generic name, and brand names differ around the world (generic names do too, granted, but not as much as brand names).

In the UK, for example, Paxil is called Seroxat and Lexapro is called Cipralex. Zoloft is called Lustral, Celexa is called Cipramil (always sounds like an antibiotic to me), Effexor is Efexor, Effexor XR is Efexor XL, and I don't think Wellbutrin is even licensed here as an anti-depressant!

A lot of people in the UK, I assume also in the US, get generic drugs prescribed for them and may not even come across the brand name for their drug. The doctor prescribes them fluvoxamine, the box they get from the chemist is generic fluvoxamine, when they talk to doctors, nurses, etc., they refer to it as fluvoxamine. I didn't even know until I looked it up just now that the brand name here is Faverin, and I've only just found out that that's what Luvox is too.

Maybe in the UK it's more common to use the generic name than it is in the States, perhaps because GPs almost never prescribe a drug by brand name. That allows the pharmacist to dispense either the branded or the generic version (in practice, they almost never dispense branded drugs once the generics are available, although for some reason a generic version of salbutamol (albuterol) doesn't get dispensed - I always get given Ventolin brand salbutamol, and so does every other asthmatic I know).

BTW it is pretty much impossible to pretend I haven't read that top bit when answering the test! That was pretty mean :-)

Doc said...

A couple of thoughts:

First, that is a fun conversation starter, agreed!

Given that there is about a 1:4 ratio of escitalopram (Lexapro) in Celexa, it makes me wonder if there is sufficient dosing in this study.

Depression is polymorphic. Co-morbid anxiety, atypical depression, and core symptoms often lead to us considering one particular antidepressant (or even specific SSRI's) over another.

Finally, you really did bias the sampling with your opening thoughts. With that kind of bias, I'm sure the The National Institute for Health and Clinical Evidence (NICE) or the FDA's next CATIE researchers will be offering you a job.

Anonymous said...

You left out the popular option: Cornucopia of meds jumbled up together

Neuroskeptic said...

I've got some comments on this study here

The methodology is novel and opaque and it doesn't tally well with the conclusions of other recent meta-analyses.

Although that said, I hear good things about citalopram and escitalopram, and citalopram works for me (much of the time) w/ no side effects except weight loss.

Sarebear said...

Well, since I'm just coming off Effexor (just on the final smidge of it this week and on Cymbalta full initial dose for last week and this week, been ramping up), I can't really say on the Cymbalta cause I know I have no idea yet (can I say, transitioning REALLY SUCKS.)

Still I put my 2¢ based on experiences with Effexor and past SSRI's, anyway.

Sarebear said...

Oh, and I recently posted about the relationship the drug rep from Wyeth (Effexor? and the newer "form" Pristiq has or seems to with my psychiatrist, on my blog. Argh.

Anonymous said...

I think it's very much a case of finding the right drug for each patient - using experience of other patients, patient wishes, patient's symptoms and perhaps intuition? Seroxat (Paxil) is an absolute life saver for me but made a friend suicidal, whereas mirtazepine (zispin?) turned me into a sleepwalking zombie and works wonders for her.
(I am dreading the withdrawal effects of seroxat...if they happen)

Anonymous said...

It's a great idea, but the problem is (forgetting unscientific, etc.) if your result reflects anything, it'll be market share multiplied by efficacy (or tolerability).

I can speak to Prozac, Zoloft and Effexor.

Zoloft "worked" but made me very apathetic. I'm sure I'd have scored well on the HAM-D, and even on side effects, but it's no way to live. Worse - I only realized how numb I'd been after I stopped taking it. At the time I was too apathetic to worry that I was too apathetic. Bad mojo imo, because you report feeling fine and you look fine, but you're living a shadow of a life and neither you or the doctor get it. I consider it my lost years.

Prozac - worked a little maybe. Maybe a little numb but not like Zoloft. No side effects to speak of. Or that I remember.

Effexor worked like crazy. Lots of side effects, but minor. No dealbreakers.

Celexa I didn't take for along enough to have an opinion. Don't remember why I stopped.

For the record MAOIs blow all of them away, both in terms of efficacy and side effects.

Anonymous said...

@nardilfan - not sure what EU laws are WRT asthma inhalers - in the US, distribution of the old-style inhalers that contained ozone-depleting CFCs is now prohibited. AFAIK, there are no generic albuterol HFA inhalers available here, just brands like Ventolin HFA, Proventil HFA, etc.

Regarding SSRIs, I've had all but Luvox and Celexa, none ATM. My ratings:

1.Effexor (venlafaxine) - worked well, took it for a long time, taken off 'as it might induce mania'. Honestly, I could use some hypomania right about now.
2.Cymbalta (duloxetine?) - felt great, but it was a pain to open the capsules and divide the pellets into 2 doses (as instructed, it didn't come in smaller doses). Didn't like the tongue/lip swelling issue, either - discontinued it b/c of that
3. Remeron (mirtazapine)- helpful for insomnia, made me feel good, but not for those (like me) who struggle with their weight
4. Lexapro (escitalopram - son of Celexa) - seemed fine w/no side effects, don't think I was on long enough to tell how I felt
5. Prozac (fluoxetine) - first one I took, but it wore out pretty fast
6. Serzone (sertraline?) - fine until it wore out and my shrink doubled the dose, causing me excruciating headaches
7. Paxil (paroxetine)- good if you want to be a cranky bee-yotch - not for me. I didn't have any withdrawal issues, though.
8. Wellbutrin - Crack heads, meth addicts and speed freaks would enjoy this; - didn't. I felt like a zombie, sleepless and stimulated.

MAOIs don't seem to have had much use here, and I don't think FDA ever approved any 'RIMAs' (next-gen MAOIs)