- Escitalopram, agomelatine, and duloxetine showed higher sustained response rates for depression than fluoxetine, according to a new review.
- While agomelatine is not currently approved by the Food and Drug Administration (FDA), doctors in the United States may recommend escitalopram or duloxetine for the long-term treatment of depression if there are no contraindications; For example, duloxetine is not suitable for people with severely impaired kidney function.
- People should talk to a healthcare professional to find the right fit based on their symptoms and medical history.
Antidepressants are some of the most commonly prescribed drugs in the United States, with active prescriptions lasting anywhere from a few weeks to several months or even years.
Identifying medications that can both alleviate symptoms and help maintain wellness is therefore an important part of long-term treatment for depression.
A new systematic review published in November in
The researchers identified three medications associated with the highest rates of sustained response: escitalopram, agomelatine, and duloxetine.
These results could help clinicians and patients make more informed decisions when considering antidepressants, although the best antidepressant will still differ for each person based on individual circumstances.
Escitalopram, agomelatine, and duloxetine performed best
The researchers explored whether certain antidepressants were more effective at achieving sustained response than others.
They found that escitalopram, agomelatine, and duloxetine showed higher sustained response rates than fluoxetine.
To determine this, they analyzed evidence from 115 randomized controlled trials, with data from more than 30,000 participants.
They found that those taking escitalopram had 62% higher odds of lasting symptom relief compared with those taking fluoxetine.
People taking duloxetine and agomelatine had 57% and 40% higher odds of lasting improvement in symptoms, respectively.
Perry Anthony Maliuanag, MD, FAPA, psychiatrist in practice at Menlo Park Psychiatry & Sleep Medicine, spoke with Medical News Today about these medications.
“Escitalopram has one of the lowest drug-drug interactions and is considered best option for those with multiple medical co-morbidity on polypharmacy. Duloxetine is a dual acting antidepressant that works on both serotonin and norepinephrine and also helps those with chronic pain syndrome,” said Maliuanag, who was not involved in the study.
He added: “Agomelatine unfortunately is not FDA approved in (the) US but I have been aware of early in its trials as a novel antidepressant. (It) works on both serotonin and melatonin, ideal for those with circadian rhythm issues with depression. However, its dose-related effect on liver enzymes, although rarely reported, has been the main obstacle.”
In a press release, Eric Ruhé, MD, PhD, Professor of Difficult to Treat Depression at Radboud University Medical Center, explained: “Of these SSRIs (recommended by many international guidelines), escitalopram now appears to be the most effective, also for long-term use. This study may have implications for future treatment guidelines.”
Why use fluoxetine as a reference?
The researchers compared 20 antidepressants against fluoxetine, which the press release describes as the “best-known antidepressant.”
Escitalopram, agomelatine, and duloxetine all performed better than fluoxetine, suggesting that, even though they are prescribed less commonly than fluoxetine, they may be a more suitable option for long-term use for some people.
“Fluoxetine was chosen as a reference mainly because it is the first in its class and has been around the longest,” said Maliuanag. “If patients are doing well on this medication, they should continue taking it.”
He added that, if an individual is “a partial or a nonresponder, they should consult their doctor prior to any decision as often an antidepressant is also selected based (on) the individual’s medical profile, medication history, and family history.”
Would doctors recommend escitalopram, agomelatine, or duloxetine?
While they performed higher than fluoxetine, escitalopram, agomelatine, and duloxetine may not be suitable for everyone.
For example, Ruhé explained that “agomelatine works well, but one of its side effects is the risk of liver failure.” It is therefore not likely to be a suitable option for people with liver problems or a high risk of liver failure.
MNT asked Maliuanag how likely or even practical it would be for clinicians to regularly recommend escitalopram, agomelatine, or duloxetine to patients with depression, and whether there were any obstacles or other contraindications that need to be considered.
“(T)here are advantages (to) each of these medications but there are certain physical conditions we watch out for. Duloxetine is best avoided with severely impaired kidney function. Escitalopram (is) used with caution with those with (a history of), or (who) may be taking other medications that may cause, QT prolongation, a condition that affects electrical activity of the heart,” Maliuanag told us.
“Agomelatine has been available in Europe and other parts of the world since 2009 but still unavailable in (the) US due to rare cases of liver injury at higher doses. Also, when prescribing an antidepressant, there is always the risk of inducing or unmasking manic symptoms, changing the diagnosis to bipolar disorder,” he added.
“Although this study shows that there are some that may seem more effective than others, antidepressants as a whole are effective but may differ in response for the individual patient. The antidepressant choice should be discussed with their clinician with the intention of looking (at) which may be the right fit based on their presenting symptoms, such as loss of appetite and having trouble sleeping, medical co-morbidities, prior or current substance use or taking other prescription medications, and personal goals.”
– Perry Anthony Maliuanag, MD, FAPA
