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.