Amitriptyline v. the rest: still the leading antidepressant after 40 years of randomised controlled trials

BACKGROUND

Tricyclic antidepressants have similar efficacy and slightly lower tolerability than selective serotonin reuptake inhibitors (SSRIs). However, there are no systematic reviews assessing amitriptyline, the reference tricyclic drug, v. other tricyclics and SSRIs directly.

AIMS

To review the tolerability and efficacy of amitriptyline in the management of depression.

METHOD

A systematic review of randomised controlled trials (RCTs) comparing amitriptyline with other tricyclics/heterocyclics or with an SSRI.

RESULTS

We reviewed 186 RCTs. The overall estimate of the efficacy of amitriptyline revealed a standardised mean difference of 0.147 (95% CI 0.05-0.243), significantly favouring amitriptyline. The overall OR for dropping out was 0.99 (95% CI 0.91-1.08) and that for side-effects was 0.62 (95% CI 0.54-0.70), favouring the control drugs. With drop-outs included as treatment failures, the estimate of the effectiveness of amitriptyline v. tricyclics/heterocyclics and SSRIs showed a 2.5% difference in the proportion of responders in favour of amitriptyline (number needed to treat 40, CI 21-694; OR 1.12 (95% CI 1.01-1.24)).

CONCLUSIONS

Amitriptyline is less well tolerated than tricyclics/heterocyclics and SSRIs, but slightly more patients treated on it recover than on alternative antidepressants.

Chemistry, pharmacology, pharmacokinetics, adverse effects, and efficacy of the antidepressant maprotiline hydrochloride

Maprotiline, a tetracyclic antidepressant with sedative properties, exhibits strong inhibitory effects on norepinephrine uptake across nerve cell membranes but interferes relatively little with serotoninergic mechanisms. The biological half-life of unchanged maprotiline in blood averages 43 hours. Though several studies suggest a more rapid onset of antidepressant effects with maprotiline than with amitriptyline or imipramine, this issue remains unresolved. The adverse effect profile of maprotiline is similar to that of the tricyclic antidepressants, except that rashes are about twice as frequent with maprotiline as with amitriptyline or imipramine. The most frequent adverse reactions are anticholinergic effects and sedation. Data suggest less frequent and severe anticholinergic side effects with maprotiline than with amitriptyline. Maprotiline may be less likely to induce orthostatic hypotension and tachycardia than standard tricyclic antidepressants, but clinically important differences in cardiovascular effects remain to be conclusively demonstrated. Many patients benefit from the convenience of once daily dosing. Maprotiline is comparable in antidepressant efficacy to the tricyclic antidepressants.

Maprotiline (Ludiomil) in depression: a report of a monitored release study of 10,000 patients in general practice

In a three-week study of 10,000 general practice patients with depressive illness, a single dose of maprotiline 75 mg at night was effective therapy in three-quarters of the patients who completed the study. At this dose the drug was well tolerated, and troublesome side-effects presented in only a small percentage of patients. Drowsiness was the most commonly reported side-effect, and the main reason for withdrawal of treatment. The drug was acceptable to most physicians, and in this study was used in a wide range of patients and over a broad spectrum of depressive illness.

A comparative study of antidepressants in the treatment of depressive states

The effect of six antidepressants has been investigated in six groups of twenty patients suffering from depressive states. The over-all response of the six groups, as well as the response of the individual target symptoms of depression according to the Hamilton Rating Scale are reported.