Choosing an antidepressant: effectiveness based pharmacoeconomics

SSRIs have been one of the major innovations in psychopharmacology in recent years. The debate over the competing claims of SSRIs and the older, cheaper TCAs has implications for clinical practice and prescribing expenditure. Several reviewers have focused on acquisition costs and stressed the higher costs associated with using SSRIs.

Recently there have been several applications of economics to the issue of whether to use SSRIs or TCAs as first-line antidepressants. Most have argued that there is an economic case for using SSRIs. Several previous papers have used modelling techniques and decision analysis to generate economic evaluations from clinical trials. This paper examines some recent studies based on retrospective evaluations of real patients and real practices. Their methods and results are summarised and discussed.

They all suggest that in practice, where concerns are with effectiveness rather than efficacy, there are advantages to be gained from using SSRIs.

There are important questions about how to perform such economic evaluations. Clinical practice has long viewed the RCT as a 'gold standard' for evaluation. Some SSRI/TCA comparisons, incorporating economic studies, are under way and will be reported on eventually. When they appear, these studies should be examined carefully for their implications for antidepressant prescribing.