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Primary care physicians and psychiatrists manage the majority of patients suffering from acute phase major depressive disorder (MDD). For most patients, antidepressant treatment is the primary choice of care. Second generation antidepressants (SGAs)—developed following the first generation of tricyclic and monoamine oxidase agents—have become the preferred drug choice because of their greater tolerability, lower risk of lethality and similar efficacy compared with first generation agents.
Clinicians prescribing SGAs face a multitude of drug choices and are the target of extensive marketing campaigns by the pharmaceutical industry. In 2007, three of the 20 top selling drugs in the USA were antidepressants with annual sales ranging from $2.3 billion (venlafaxine XR (Effexor XR)) to $1.4 billion (duloxetine (Cymbalta)).1 At the time of writing, 13 different SGAs have been approved for the treatment of major depression in the USA and Canada and two additional drugs (reboxetine, milnacipran) are available in some European countries. Some of these drugs are now available as generic medications, others are still patent protected. Economically, drug choice matters. The US Consumers Union found that in 2008 the average monthly costs of treatment with second generation antidepressants in the USA varied from $20 to $400 depending on the medication of choice.2 The study conducted by Cipriani and colleagues3 addressed an ongoing challenge for clinicians: how to choose among antidepressant treatments and select the best drug for an individual patient suffering from an episode of major depression (see page 107).
Why such a study is important
The burning question for patients and clinicians is whether differences in costs are substantiated by differences in benefits and harms. Evidence based data to answer this question and to guide selection of treatments has been limited. Because of the lack of available direct head to head comparisons, prior systematic reviews have been able to say little about …
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