Tricyclic antidepressants should not be first line treatment

EDITOR—In his editorial Edwards correctly points out the high rate of recurrence of disease among patients with major depression and the importance of long term treatment.1 We dispute his advice to use tricyclic antidepressants as first line treatment.

He states that the dropout rate in clinical trials is 1-5% less in patients given selective serotonin reuptake inhibitors than in patients given tricyclic antidepressants. A meta-analysis of 62 randomised controlled trials found that the total discontinuation rate was 10% lower with selective serotonin reuptake inhibitors and the dropout rate due to side effects 25% lower.2 These dropout rates imply that patients are being inadequately treated with tricyclic antidepressants and may require further psychiatric treatment and possibly admission to hospital.

Edwards admits that death is more likely to result from overdoses of older tricyclic antidepressants than from overdoses of newer compounds. He quotes a single questionnaire study to back up his claim that this difference may be due to doctors prescribing older antidepressants to patients who are more prone to suicide. The Health of the Nation sets a target for reducing the rate of suicide by 15% by 2000 and suggests that this may be achieved by reducing the availability of means to do so.3 The famous reduction in suicide rates that followed the introduction of natural gas as well as more recent research supports this policy.4

Edwards calculates the average net ingredient cost of an NHS prescription for a selective serotonin reuptake inhibitor in 1995 to be =A327.21. Our calculations based on figures obtained from a 1995 edition of the British National Formulary show it to be =A323.43. He uses his figures to extrapolate the increase in cost that would be seen if selective serotonin reuptake inhibitors were used as first line treatment for all patients currently …