Long-term outcomes of initial antidepressant drug choice in a "real world" randomized trial.
OBJECTIVE
To compare the long-term clinical, quality-of-life, and economic outcomes after an initial prescription for fluoxetine, imipramine hydrochloride, or desipramine hydrochloride.


METHODS
Randomized, controlled trial.


METHODS
Primary care clinics of a staff-model health maintenance organization in the Seattle, Wash, area.


METHODS
Four hundred seventy-one adults beginning antidepressant drug treatment for depression.


METHODS
Random assignment of initial medication (desipramine, fluoxetine, or imipramine), with treatment (dosing, medication changes or discontinuation, and follow-up visits) managed by a primary care physician.


METHODS
Interviews at baseline and at 6, 9, 12, 18, and 24 months examined medication use, clinical outcomes (Hamilton Depression Rating Scale and depression subscale of the Hopkins Symptom Checklist), and quality of life (Medical Outcomes Study SF-36 Health Survey). Medical costs were assessed using the health maintenance organization's accounting data.


RESULTS
Patients assigned to fluoxetine therapy were significantly more likely to continue taking the initial antidepressant but no more likely to continue any antidepressant therapy. The fluoxetine group did not differ significantly from either tricyclic drug group on any measure of depression severity or quality of life. For 24 months, antidepressant drug costs were approximately $250 higher for patients assigned to fluoxetine therapy, but total medical costs were essentially identical.


CONCLUSIONS
Initial selection of fluoxetine or a tricyclic antidepressant drug should lead to similar clinical outcomes, functional outcomes, and overall costs. Differences in antidepressant prescription costs are blunted by the large minority of tricyclic-treated patients who switch to use of more expensive medications. Restrictions on first-line use of fluoxetine in primary care will probably not reduce overall treatment costs.
Center for Health Studies, University of Washington, Seattle, USA. simon.g@ghc.org
G E
GE
Simon
J
J
Heiligenstein
D
D
Revicki
M
M
VonKorff
W J
WJ
Katon
E
E
Ludman
L
L
Grothaus
E
E
Wagner
D018759:Adrenergic Uptake Inhibitors / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000928:Antidepressive Agents / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D018687:Antidepressive Agents, Second-Generation / Q000627:therapeutic use; D000929:Antidepressive Agents, Tricyclic / Q000627:therapeutic use; D003866:Depressive Disorder / Q000188:drug therapy* / Q000191:economics; D003891:Desipramine / Q000627:therapeutic use; D005260:Female; D005473:Fluoxetine / Q000627:therapeutic use; D006801:Humans; D007099:Imipramine / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
D018759:Adrenergic Uptake Inhibitors; D000928:Antidepressive Agents; D018687:Antidepressive Agents, Second-Generation; D000929:Antidepressive Agents, Tricyclic; D003891:Desipramine; D005473:Fluoxetine; D007099:Imipramine; D017367:Selective Serotonin Reuptake Inhibitors