What Is The Best First Line Antidepressant?


Vol 6 # 1

Alan Eppel


Many SSRIs and SNRIs are considered effective as first line choices for the treatment of Major Depression. However the short term nature of randomized controlled trials does not allow the identification of the most effective first and second line choices.  A recent extensive meta-analysis  did not resolve this question due to a number of methodological and study concerns (1,2).

An anonymous survey, using Survey Monkey,  was conducted to determine which medications psychiatrists choose in normal clinical practice.

One hundred and ten psychiatrists were sent a link to the survey by email.  Fifty one psychiatrists completed the survey. Nearly all of the psychiatrists worked in the same Academic Health Sciences Centre.


Survey Question:

“Which antidepressant would you choose as your first choice for a 30-year-old male who presents with a first episode of major depression? No prior history of any psychiatric or medical problems. No substance use. The patient is single and has a good job.

After 8 weeks at maximal doses the patient is minimally improved. You decide to switch to a different antidepressant. Which one of the following would you choose?”


Antidepressant First Choice Percentage Second Choice Percentage
escitalopram 19 37.25 5 9.62
sertraline 13 25 13 25
citalopram 7 14 0 0
fluoxetine 4 8 0 0
bupropion 4 8 6 12
vortioxetine 3 6 0 0
mirtazapine 1 2 3 6
venlafaxine 0 0 22 42
nortriptyline 0 0 1 2
duloxetine 0 0 1 2
desvenlafaxine 0 0 1 2
paroxetine 0 0 0 0
fluvoxamine 0 0 0 0
moclobemide 0 0 0 0
Total 51 52



This online survey gives a snapshot of current clinical choices made in one specific academic setting. The results show a consistent preference for escitalopram and sertraline as first line and venlafaxine and sertraline as second line. This survey cannot be generalized across sites or applied to more complex and co-morbid presentations. Nevertheless the choices are consistent with much of the existing literature and provide no support for the use of some of the newer agents in this context.



1.Eppel A. Network meta-analysis of antidepressants: a bridge too far. Journal of Psychiatry Reform, January 2019.

2. Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and
acceptability of 21 antidepressant drugs for the acute treatment of adults with major
depressive disorder: a systematic review and network meta-analysis. Lancet 2018;
published online Feb 21. http://dx.doi.org/10.1016/S0140-6736(17)32802-7

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