Tricyclic antidepressants and selective serotonin reuptake inhibitors effective for depression in primary care

Clinical question: 
How effective are tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) in patients with depression in primary care?
Bottom line: 
Compared to placebo, TCAs and SSRIs were effective in reducing depression (measured by the Hamilton depression scale and the Montgomery-Asberg scale) in adults under 65 years. The NNT* for TCAs ranged from 7 to 16 (median = 9), and for SSRIs from 7 to 8 (median = 7). The NNH** (withdrawal due to side effects) ranged from 4 to 30 for TCAs, and 20 to 90 for SSRIs. Adverse effects not leading to medication cessation seemed to be more common with TCAs than SSRIs. *NNT = number needed to treat to benefit 1 individual **NNH = number needed to treat to cause harm to 1 individual
Caveat: 
Most of the studies were supported by funds from pharmaceutical companies and were of short duration, typically 6 to 8 weeks. There was no dose information on SSRIs, and the authors were unable to comment on the appropriate duration of treatment for either TCAs or SSRIs.
Context: 
Depression is very common in primary care, with a 12-month prevalence of 18.1%. There is considerable overlap with anxiety and substance use.1 It is a paradox that, while the vast majority of patients with clinical depression is dealt with in primary care, most of the research findings upon which decisions are made have come from secondary care patients.
Review CD#: 
CD007954
PEARLS No: 
186
Date: 
July, 2009
Authored by: 
Brian R McAvoy