Are SSRIs a Cost-Effective Alternative to Tricyclics?

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are more expensive than tricyclics. Reports have suggested that SSRIs are cost-effective because they are better tolerated and safer in overdose. METHOD: A systematic review of all randomised controlled trials (RCTs), meta-analyses, and cost-effectiveness studies comparing SSRIs and tricyclic antidepressants (TCAs). RESULTS: None of the RCTs provided an economic analysis and there were methodological problems in the majority which would preclude this approach. Meta-analyses suggest that clinical efficacy is equivalent but slightly fewer patients prescribed SSRIs drop out of RCTs. Cost-effectiveness studies have been based on crude 'modelling' approaches and over-estimate the difference in attrition rates and the cost of treatment failure. It appears impossible to evaluate the economic aspects of suicide because of its rarity. CONCLUSIONS: There is no evidence to suggest that SSRIs are more cost-effective than TCAs. The debate will only be concluded when a prospective cost-effectiveness study is done in the setting of a large primary care based RCT.