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EDITORIALS: J Guy Edwards Long term pharmacotherapy of depression BMJ 1998; 316: 1180-1181 [Full text]

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Choice of drug determines life quality

Chris Manning   (20 July 1998)

Choice of drug determines life quality 20 July 1998
Chris Manning, GP Principal Twickenham Send response to journal: Re: Choice of drug determines life quality	This article, if it had related to asthma, would have concluded by recommending that salbutamol and beclomethasone inhalers should only be used by patients unable to tolerate isoprenaline or Do-Do tablets. Why do we persist in this naive notion that the only advantage the SSRIS have over TCAs is in their lack of cardiotoxicity? And why should SSRIs only be used in those " who are prone to accidents"? GPs are now presumably in possession of the necessary clairvoyant powers. If any secondary care specialist still thinks that TCAs in doses less than 125mg a day are acting as placebos, I would be very happy to issue my "TCA Taste challenge" and invite them to take such a dose for a minimum of 4-6 weeks and let me know how they feel. If they are unhappy to start at this dose, then I would be quite happy for them to start at 25mg once a day and work up to the commonly stated threshold of 125mg od. If no-one is prepared to take me up on this, then I can only conclude that this placebo notion is untrue and that psychiatrists really do not believe this any more than most GPs, who, whilst constantly being hammered for their inability to prescribe at therapeutic doses, could be funded to prescribe SSRIS first-line (as some are in some Health Authorities) or their clinical practice should be studied in more depth, rather than just analysed at the point of prescribing on the assumption that they are misled and unable to tell a toxic drug type when they see one. Could it be that, in this case, evidence-based medicine (which includes personal experience) has demonstrated to a large number of these qualified doctors (and I am not including here many who have no idea how to treat depression), that doses lower than 125mg od are effective, when prescribed for sufficient periods of time? As a sufferer, who has taken 175mg amitriptyline for 7 years and am now on an SSRI, I suspect most caring GPs use TCAs in so-called "sub-therapeutic doses", at least for moderate depression, because they "know" the toxicity of these drugs, that they can be used to overdose and that therapeutic doses are almost incompatible with having a worthwhile conscious existence.