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Doubt cast on NICE advice over tricyclics and SSRIs

A new study has cast doubt on a claim from NICE that there is 'A-grade' evidence to recommend GPs abandon first-line use of tricyclics in favour of SSRIs.

Draft NICE guidance on treatment of depression awards the highest rating to evidence supporting a recommendation that SSRIs are 'as effective as tricyclic antidepressants and less likely to be discontinued due to side-effects'.

But a new meta-analysis of randomised trials based in primary care has uncovered 'fundamental gaps' in the evidence on the relative efficacy of the two groups of drugs.

Stephen Macgillivray, leader of the meta-analysis, said the available data 'suggested' equal efficacy between SSRIs and tricylics. But the evidence was 'sparse and of poor quality', with most trials supported by commercial funding.

Mr Macgillivray, research fellow in epidemiology at the University of Dundee, said

SSRIs were 'significantly' better tolerated than tricyclics.

Patients taking tricyclics were 30 per cent more likely to stop treatment because of side-effects, according to data presented to the Society for Social Medicine annual conference earlier this month.

The findings will add to the confusion facing GPs. The BNF says the difference in tolerance rates between the two groups of drugs 'is too small to justify always choosing an SSRI as first-line treatment'.

Professor André Tylee, professor of primary care mental health at King's College London, who sat on the committee that drafted the NICE guidelines, said patient views were taken into account but recommendations would not be finalised until March.

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