Andrea Cipriani, MD, University of Verona, Verona, Italy, and colleagues analysed results of 117 randomised controlled trials from 1991 to 2007, which compared the effects of these antidepressants in more than 25,000 patients with major depression.

The drugs tested were bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, milnacipran, mirtazapine, paroxetine, reboxetine, sertraline, and venlafaxine. The main outcomes were the proportion of patients who responded to or dropped out of the allocated treatment.

Sertraline and escitalopram were found to be the best antidepressants overall in terms of efficacy and acceptability. Sertraline was more efficacious than duloxetine (by 30%); than both duloxetine and fluvoxamine (by 27% for both); 25% fluoxetine (by 25%); paroxetine (by 22%); and reboxetine (by 85%).

Escitalopram was more efficacious than duloxetine (by 33%); fluoxetine (by 32%); fluvoxamine (by 35%); paroxetine (by 30%); and reboxetine (by 95%). As with sertraline and escitalopram, mirtazapine and venlafaxine were also more efficacious than these other drugs.

However, escitalopram and sertraline showed the best profile of acceptability, leading to significantly fewer discontinuations of treatment than did duloxetine, fluvoxamine, paroxetine, reboxetine, and venlafaxine.

"The most important clinical implication of the results is that escitalopram and sertraline might be the best choice when starting a treatment for moderate to severe major depression because they have the best possible balance between efficacy and acceptability," the authors wrote.

SOURCE: The Lancet

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