Long term pharmacotherapy of depression

BMJ 1998;317:1157 ( 24 October )

Letters

Long term pharmacotherapy of depression

Tricyclic antidepressants should not be first line treatment

Impact of side effects of treatment is important in older patients

Patients can help doctors decide on treatment

Author's reply

Tricyclic antidepressants should not be first line treatment

The first 150 words of the full text of this article appear below.

EDITOR $---$ In his editorial Edwards correctly points out the high rate of recurrence of disease among patients with major depressionand the importance of long term treatment.¹ We dispute hisadvice to use tricyclic antidepressants as first linetreatment.

He states that the dropout rate in clinical trials is 1-5% less in patients given selective serotonin reuptake inhibitorsthan in patients given tricyclic antidepressants. A meta-analysisof 62 randomised controlled trials found that the total discontinuationrate was 10% lower with selective serotonin reuptake inhibitorsand the dropout rate due to side effects 25% lower.² Thesedropout rates imply that patients are being inadequately treatedwith tricyclic antidepressants and may require further psychiatrictreatment and possibly admission tohospital.

Edwards admits that death is more likely to result from overdoses of older tricyclic antidepressants than from overdoses ofnewer compounds. He quotes a single questionnaire study to backup his . . . [Full text of this article]