Escitalopram(Cipralex) is one of the isomeric forms of the drug citalopram. The manufacturers found that citalopram actually consisted of two versions of the same molecule, with one apparently more active than the other. They refined this 'more active' version into a new drug.
The promotional material supporting escitalopram includes a trial1 that put it head-to-head with citalopram in patients with major depression (i.e. not routine primary care patients). The trial looked at reduction in MADRAS Depression score (a validated scale).
At the end of the trial period of 8 weeks escitalopram was statistically better than citalopram. However, on closer examination of the paper the statistical difference may not equate to a clinical difference. The difference in MADRAS scores between the two drugs was 2 points with confidence intervals on each estimate of approximately 12.
Clinically a difference of 2 points measured on a scale of 60 is not going to be noticeable. Furthermore, although the paper demonstrates statistical difference the confidence intervals on the point estimates overlap massively and therefore the findings are not conclusive.
Action: There are three things to consider here:
- Escitalopram has not been shown to be clinically better than citalopram. Citalopram or Fluoxetine remain first line antidepressants, based upon predominant symptoms and where an antidepressant is clinically appropriate. See NICE Guideline
- This trial was in Major Depression and therefore does not extrapolate to primary care patients with Minor Depression. Antidepressant medication is not a suitable first line treatment for minor depression, unless it is recurrent.
- This drug has not been placed on the Lancashire Care Trust Formulary so patients who are treated and then referred may be changed anyway.
- Prospective, multicentre, randomized, double-blind study of the efficacy of escitalopram versus citalopram in outpatient treatment of major depressive disorder. International Clinical Psychopharmacology. 20(3):131-137, May 2005. Moore, N; Verdoux, H; Fantino, B