Several placebo-controlled trials have shown that
milnacipran, 100 mg/day in two doses, is an effective antidepressant in
both the ambulatory and hospital settings. Comparative trials against
tricyclic antidepressants (imipramine and clomipramine) failed to show
that milnacipran was any more effective. Milnacipran has not been
compared with specific or non specific MAOI antidepressants. As regards
non tricyclic-non MAOI antidepressants, milnacipran has been compared
only to two specific serotonin reuptake inhibitors, fluvoxamine and
fluoxetine. The trials cannot convince us of a difference in efficacy
between the two types of treatment. The claimed superiority of
milnacipran over serotonin reuptake inhibitors is not based on firm
evidence of better efficacy or fewer adverse effects. The overall
tolerability of milnacipran is similar to that of fluoxetine and
fluvoxamine. Relative to the tricyclic antidepressants, milnacipran has
fewer atropinic effects (sedation and sweating). In contrast, it cause
more dysuria, and cannot, therefore, replace tricyclics in elderly men
with prostate disorders. Tricyclics remain the preferred first-line
antidepressant drugs. When they are contraindicated or poorly tolerated,
many other antidepressants with well-documented risk-benefit ratios are
available.
