The drugs reviewed included SSRIs like sertraline (Zoloft) and fluoxetine (Prozac); serotonin-norepinephrine reuptake inhibitors (SNRIs) like duloxetine (Cymbalta) and tricyclics such as amitriptyline.<\/p>\n
Professor Andrea Cipriani from the University of Oxford, one of the study\u2019s authors, told the BBC that there had been a push for \u201cgeneric, cheap medications\u201d that meant 85 per cent of antidepressant prescriptions in the UK were for just three SSRI drugs: citalopram, sertraline and fluoxetine.<\/p>\n
The findings of the report, he said, could result in that figure being \u201cdramatically\u201d reduced, with \u201cmore people accessing better treatments\u201d.<\/p>\n
In terms of the study\u2019s limitations, it is worth noting that some of the fluctuations recorded were small, and not necessarily clinically significant. The trials evaluated in the analysis were also relatively short \u2014 and side-effects such as sexual dysfunction were not monitored.<\/p>\n
Philip Cowen, professor of psychopharmacology at the University of Oxford, explains how this new data could affect prescribing \u2014 and what patients can learn from it. <\/p>\n
Of course, every person is different so any decision must be made in consultation with your GP.<\/p>\n
What do I need to know about SSRIs?<\/p>\n
\u201cMost antidepressant prescribing is done in primary care by GPs and they would usually prescribe SSRI drugs such as sertraline or fluoxetine, first-line,\u201d Cowen says. \u201cCitalopram and escitalopram are also used frequently but the drug data sheets carry warnings that they can increase the QTc interval in the electrocardiogram [ECG].\u201d This is a measure of the time it takes for the heart\u2019s ventricles to contract and relax, corrected for heart rate, and significant increases in it elevate the risk of cardiac arrhythmias, says Cowen.<\/p>\n
He points out that this effect was not demonstrated in the meta-analysis, but it is worth noting because it\u2019s part of the reason citalopram and escitalopram are prescribed less than other SSRIs by GPs. The primary dangers of cardiac arrhythmias include stroke, heart failure and sudden cardiac arrest.<\/p>\n
On the plus side, citalopram was not associated with a rise in systolic blood pressure and resulted in a moderate drop in weight in the study. Fluoxetine was also associated with participants shedding some pounds but was linked to higher systolic blood pressure. Of the other SSRIs, \u201cFluvoxamine is very little used in primary care because it is less tolerated than other SSRIs,\u201d according to Cowen. The study found that it tended to increase systolic blood pressure and cause weight gain. Paroxetine is also used less because it has been associated with worse withdrawal symptoms than other SSRIs.<\/p>\n
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I\u2019m choosing between sertraline and fluoxetine \u2014 what should I consider?<\/p>\n
In the study both drugs resulted in a moderate amount of weight loss. However, fluoxetine increased systolic blood pressure, unlike sertraline \u2014\u2013 but the researchers\u2019 confidence in the evidence for this comparison was recorded as \u201cvery low\u2019\u2019. Meanwhile, alkaline phosphatase (ALP) levels, which can indicate a problem with the liver or bones, were elevated in those who took sertraline but not in those on fluoxetine. Bottom line? \u201cAny hint of liver problems, you might want to avoid sertraline.\u201d <\/p>\n
NHS guidance warns that \u201csertraline can cause liver damage in rare cases but is generally considered safe for patients with pre-existing liver disease if a lower dose is used. Patients with liver disease have increased sensitivity to sertraline.\u201d<\/p>\n
Fluoxetine also has one of the longest half-lives among SSRIs<\/a>, which is the time it takes for the amount of the drug in the body to be reduced by 50 per cent. This is a significant factor in its clinical use because it enables a smoother reduction in antidepressant blood levels when discontinued.<\/p>\n \u201cFluoxetine has got a very long duration of action in the body \u2014 longer than sertraline. That means that you\u2019re less likely to get unpleasant withdrawal symptoms and that\u2019s the advantage,\u201d Cowen says.<\/p>\n \u201cEqually, the long half-life means that if you want to swap to another antidepressant, that can create problems because you have to wait for it to fully leave your system.\u201d Whereas with sertraline, \u201cafter a few days, it\u2019s all gone\u201d, Cowen says. Fluoxetine may still cause medicine interactions about five or six weeks after stopping, according to research.<\/p>\n