Should Anxiety and Insomnia Influence Antidepressant Selection: A Randomized Comparison of Fluoxetine and Imipramine
J Clin Psychiatry 1998;59(2):49-55
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Background: The more sedating antidepressants
are often recommended for patients presenting with anxiety or
insomnia. We examine whether baseline anxiety or insomnia
symptoms (1) show differential response to fluoxetine or
imipramine or (2) predict differences between drugs in overall
clinical response or likelihood of medication discontinuation.
Method: 336 health maintenance organization
primary care patients beginning antidepressant treatment for
depression were randomly assigned to an initial prescription for
fluoxetine or imipramine. All subsequent care (medication dosage,
change, or discontinuation) was managed as usual by the primary
care physician. The 17-item Hamilton Rating Scale for Depression
(HAM-D) and the Hopkins Symptom Checklist (SCL) anxiety and
depression subscales were administered prior to randomization and
1 month later.
Results: Rates of improvement in insomnia (HAM-D
insomnia items), agitation (HAM-D agitation item), and anxiety
(SCL anxiety subscale) were essentially identical in the two
treatment groups. Baseline level of insomnia did not predict
significant differences between randomization groups in
improvement in overall HAM-D score (p=.44) or SCL depression
subscale (p=.44). Similarly, baseline level of anxiety did not
predict significant differences in improvement in HAM-D (p=.19)
or SCL depression subscale (p=.31). Patients assigned to
fluoxetine were significantly less likely to change or
discontinue antidepressant medication during the first month, but
this difference did not vary according to baseline level of
insomnia (p=.68) or anxiety (p=.25).
Conclusion: Among patients with moderate
depression, baseline levels of insomnia or anxiety should not
influence the choice of fluoxetine or imipramine as an initial