People with depression have a higher incidence of cardiovascular disease and mortality from cardiovascular disease than people without depression.1 Ideally, the use of antidepressants should not add to this risk. Depression may also provoke suicide, so toxicity in overdose is a crucial consideration when choosing an antidepressant.

Older tricyclic antidepressants may increase mortality from cardiovascular disease when used therapeutically and are often fatally toxic in overdose, whereas selective serotonin reuptake inhibitors (SSRIs) show little if any cardiotoxicity at any dose, although, their antiplatelet effect has potential for harm.2 The serotonin-noradrenaline reuptake inhibitor venlafaxine has been thought to show cardiovascular toxicity somewhere between that of tricyclics and SSRIs, so its use has been restricted in some countries. In the linked case-control study (doi:10.1136/bmj.c249), however, Martinez and colleagues challenge the notion that venlafaxine is more cardiotoxic than SSRIs.3

In their study using data from the general practice research database in the United Kingdom, which looked at 207 384 first …