Education And Debate

Controversies in Management: New or old antidepressants? New is better

BMJ 1994; 309 doi: (Published 12 November 1994) Cite this as: BMJ 1994;309:1280
  1. G Harrison
  1. Academic Department of Psychiatry, Mapperly Hospital, Nottingham NG3 6AA.

    To justify a claim that a new drug is much better than old and well tried formulations it is necessary to show greater effectiveness, fewer side effects, or significantly reduced costs to the purchaser. There is no evidence that the “new” antidepressants, such as lofepramine and the selective serotonin reuptake inhibitors, are any more effective than older treatments, but they are certainly equally effective.1,2 Some of the new antidepressants have already been in use for several years and acquired a sound track record in general clinical experience. Though further prospective trials are needed in severe and chronic forms of depression,3 experimental evidence for tricyclic antidepressants in these conditions is similarly limited.

    Benefits of new drugs

    The advantages of the new treatments are that they have fewer unpleasant side effects.4 Because of the absence of antimuscarinic effects, most of the new antidepressants have few of the troublesome effects of dry mouth, constipation, blurred vision, and tachycardia, and sedation is less of a problem because new treatments cause little blockade of histamine receptors. Less ataxia and incoordination in elderly people reduce the risk of falls, and postural hypotension is uncommon because of the absence of (alpha)1 receptor blockade. Weight gain and carbohydrate craving, a serious concern of many patients, are much reduced. These side effects are always unpleasant for patients, sometimes distressing, and occasionally fatal.

    Tricyclic antidepressants are a well recognised cause of cardiotoxicity …

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