The management of depression. Part 2. The place of the new antidepressants.

Four years since the introduction of fluoxetine into Australian clinical practice, and two years since the availability of moclobemide, it is now possible to comment with some degree of certainty about the place of the new antidepressants. There do not appear to be any major complications or adverse effects associated with the recently marked antidepressants. While these medications clearly share their own similar and specific side effects, these problems are less frequent and severe than those experienced with the TCAs. Additionally, it has become obvious that they have fewer cardiac effects and possess a lower toxicity on overdose than the older classes of antidepressants. The differences in adverse effects between the various SSRIs appear to be minimal. Does this mean that the SSRIs, moclobemide and mianserin should be the treatment of first choice for depression? On balance, the evidence presented in this article would suggest rather that the new agents and TCAs should all be considered first-line agents. While discontinuation rates due to adverse effects are clearly less frequent with the new antidepressants, the currently available data do not indicate any difference in drop-out rates when discontinuation due to lack of efficacy is also incorporated into the equation. Irrespective of cost issues, the possible greater effectiveness of the TCAs in melancholic depression must also be taken into account. In conclusion, the advent of the SSRIs, moclobemide and mianserin has clearly been a major advance in the treatment of depression, and is already leading to major shifts in the pattern of antidepressant prescribing.(ABSTRACT TRUNCATED AT 250 WORDS)