Letters

Low dosage tricyclic antidepressants in depression

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7387.499/a (Published 01 March 2003) Cite this as: BMJ 2003;326:499

Giving low dose tricyclics is not justified by evidence

  1. Hugh M Jones, specialist registrar ([email protected])
  1. Ward DB2, Maudsley Hospital, London SE5 8AZ
  2. East Glamorgan Mental Health Unit, Church Village, Rhondda Cynon Taff, South Wales CF38 1AB
  3. London Health Sciences Centre, London, ON, Canada N6A 4G5
  4. Department of Psychiatry, Nagoya City University Medical School, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
  5. Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Ospedale Policlinico, I-37134 Verona, Italy
  6. Cochrane Collaboration Depression, Anxiety and Neurosis Group, Health Services Research, King's College Institute of Psychiatry, London SE5 8AF

    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.

    Footnotes

    • Competing interests HMJ has received a small grant for a research study on olanzapine by Eli Lilly.

    References

    1. 1.

    Evidence to change current guidelines is insufficient

    1. Imad M Ali, locum consultant psychiatrist ([email protected])
    1. Ward DB2, Maudsley Hospital, London SE5 8AZ
    2. East Glamorgan Mental Health Unit, Church Village, Rhondda Cynon Taff, South Wales CF38 1AB
    3. London Health Sciences Centre, London, ON, Canada N6A 4G5
    4. Department of Psychiatry, Nagoya City University Medical School, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
    5. Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Ospedale Policlinico, I-37134 Verona, Italy
    6. Cochrane Collaboration Depression, Anxiety and Neurosis Group, Health Services Research, King's College Institute of Psychiatry, London SE5 8AF

      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 …

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