GPs should become familiar with one or two antidepressants from each class

EDITOR—Livingston and Livingston cast a sceptical eye over the newer antidepressants in relation to the treatment needs of older people with depression.1 Their editorial contained omissions and inaccuracies. They state that subjects aged over 64 with physical disease were excluded from “all the trials cited” in the editorial yet quote research (their reference 5) that addressed precisely this group.

Likewise, they claim that fluoxetine is the “only newer antidepressant that has been evaluated clinically in depressed patients with organic brain disease” but cite two papers, one concerning citalopram and the other moclobemide, that have evaluated depression in old people with dementia. They overlook important sources of information—for example, the comprehensive report of the National Institutes of Health in 1991, recently updated2—and they lump together all older people, when clearly there are important differences between a fit 65 year old and a frail 85 year old.

The debate they are trying to promote is a tired one. Older people are prone to side effects and have contraindications to a large number of drugs (including some older tricyclic antidepressants), so it makes sense to have a choice; that is precisely what the newer antidepressants offer to older patients. Having a choice improves outcome. In one study of older people, sequential antidepressant regimens that used different classes of antidepressants resulted in a recovery rate of over 80%.3 The newer antidepressants are here to stay. The important questions are not whether they should be used at all but their place alongside psychological approaches in cases resistant to treatment with a first line antidepressant and in the prevention of recurrence

A more helpful message would be to encourage practitioners who treat older patients to become familiar with one or two antidepressants from each class, as recommended by the Royal Colleges of …