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LETTERS: Damian Gamble, Jogin Thakore, Robert Tobiansky, Chris Manning, and J Guy Edwards Long term pharmacotherapy of depression BMJ 1998; 317: 1157 [Full text]

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Longterm pharmacotherapy of depression

Imad M Ali   (2 November 1998)

Longterm pharmacotherapy of depression 2 November 1998
Imad M Ali Send response to journal: Re: Longterm pharmacotherapy of depression	Tobiansky's response1 to a recent editorial2 cites my study of long- term antidepressant prescription in primary care,3 and suggests that preferential treatment with selective serotonin re-uptake inhibitors (SSRI) over tricyclic antidepressants (TCA) may resolve the problem of prescription of subtherapeutic doses. I report preliminary findings from a five year follow-up study of the original cohort of patients described in my earlier research.3 This work did not set out to clarify differences between antidepressant groups, but attempted to assess the mid to long-term prognosis of depressed patients treated in general practice, and to relate this to the dose of antidepressant prescribed. Depressive symptoms were assessed by the shortened form of the Beck Depression Inventory (BDI-13) and the effect of these depressive symptoms on daily life was assessed by a shortened 45- item version of the Sickness Impact Profile (SIP).4 The original study showed that in one general practice, of 222 patients receiving long-term antidepressants for a depressive illness, 62% of respondents to a postal survey reported moderate or severe depressive symptoms, and of these only 50% were receiving a therapeutic antidepressant dose.3 Five years later, examination of 195 surviving patients of the original cohort revealed surprisingly little change. Again 62% of respondents reported moderate or severe depressive symptoms and analysis of the SIP scores suggested that these patients also experienced significant impairment in daily functioning. Furthermore only 55% of these moderate-severely depressed patients were now in receipt of a therapeutic antidepressant dose. The magnitude of this increase (5%) is disappointing and can be accounted for by a shift in prescribing away from tricyclic and second generation or tetracyclic antidepressants to SSRI's; treatment with SSRI's rose from 18% of the original cohort to 37% in 1998. Debating the relative merits of different classes of antidepressants distracts one from the surely more important question of why general practitioners continue to prescribe low doses of tricyclics. If this is because they are unaware of patients' persisting depressive symptoms then the case for regular review of these patients becomes indisputable. Review may lead to an increase in dose of, or a change in the antidepressant prescribed, or referral to a specialist for advice or psychotherapy; it provides an opportunity to reduce the substantial morbidity demonstrated in these patients. Patients on long-term pharmacotherapy for depression are as deserving of regular review as patients with other chronic conditions such as diabetes or asthma. Dr Imad M Ali Senior registrar in Psychiatry Cefn Coed Hospital Waunarlwydd Road Cockett Swansea SA2 OGH. 1 Tobiansky R. Impact of side effects of treatment is important in older patients. BMJ 1998;317:1157. (24 October) 2 Edwards JG Long term pharmacotherapy of depression. BMJ 1998;316:1180-1. 3 Ali IM Long-term treatment with antidepressants in primary care. Psychiatr Bull 1998;22:15-9. 4 Bergner M, Bobbitt RA, Carter WB, Gilson, BS The sickness impact profile: development and final revision of a health status measure. Medical Care 1981;19(8):787-805