Giving low dose tricyclics is not justified by evidence

EDITOR—The meta-analysis by Furakawa et al must be considered downright naughty.1 While masquerading as a contribution to an academic debate about appropriate antidepressant treatment it actually does little more than endorse the widely held prejudice in favour of using low dose tricyclics in depression. Published in a widely read UK general medical journal, it will inevitably encourage a practice that is not encouraged by either the Royal College of Psychiatrists or the American Psychiatric Association.

The subject of optimal dosage of tricyclics remains controversial, but the value of treatment with tricyclic antidepressants at standard dosage compared with placebo is abundantly clear. As Furakawa et al concede but perhaps do not emphasise sufficiently, the evidence for low dose tricyclic antidepressants is of generally poor quality. Many of the trials used in their analysis took place before standardised diagnostic or outcome criteria were commonplace.

What is less clear is the motivation for their undertaking. Fluoxetine is now available in generic preparations for about £7 per month, significantly reducing the financial advantage of older antidepressants. Some evidence supports the use of tricyclics in severe depression, but presumably the authors would not recommend low dose tricyclics in such patients. The chronic severe nature of depression would make it unethical to recommend a treatment without a secure evidence base. Being charitable, one can only hope that the therapeutic advice was added to add colour to an otherwise unexceptional meta-analysis.

Evidence to change current guidelines is insufficient

EDITOR—The study by Furukawa et al consists of two separate analyses looking at quite different things so it is difficult to draw any firm conclusions.1

The first meta-analysis of 35 …