SSRIs may well be best treatment for elderly depressed subjects

EDITOR—In his review of mental health in old age Macdonald advocates the use of dothiepin as a first line antidepressant.1 He suggests that the selective serotonin reuptake inhibitors should usually be reserved for cases in which tricyclic antidepressants fail or are contraindicated. Although it is impossible in a brief review article to cover fully the advantages and disadvantages of different drugs, we think it important to highlight that, as in younger patients, rational choice of a first line antidepressant in elderly people is difficult and controversial. This is particularly so because of a dearth of antidepressant studies in late life, especially in frail, physically ill patients and those who are cognitively impaired.2

Macdonald states that selective serotonin reuptake inhibitors may be slow to act. Even if this is the case, the slow titration to an effective dose that is necessary with tricyclic antidepressants (up to 42 days, according to the regimen Macdonald gives for dothiepin) may delay the onset of antidepressant effect to a much greater extent. Furthermore, discontinuation of treatment is more common with tricyclics3 and, if it leads to a change in antidepressant, will cause a further delay in effective treatment. Therefore, treatment with selective serotonin reuptake inhibitors is likely to lead to many depressed patients being treated effectively sooner than if they were given other drugs. In general practice, selective serotonin reuptake inhibitors are more likely than tricyclic antidepressants to be prescribed in a therapeutic dose in elderly patients.4 Undertreatment is an important reason for poor prognosis in some studies of elderly subjects,5 and this may be one of the most important reasons for advocating the use of selective serotonin reuptake inhibitors by general practitioners.

Current research has not shown clear superiority of one antidepressant over another in terms of efficacy. The choice of a first line agent therefore remains difficult, controversial, and often idiosyncratic. Further comparisons between antidepressants in elderly patients are needed. We believe that rational choice is best made after consideration of factors such as history of tolerability of and response to a particular agent; type of depression (agitated or retarded); concurrent drug treatment and possible drug interactions; compliance; concurrent physical illness; and liability to particular side effects such as postural hypotension, cognitive impairment, and sedation. After such consideration, selective serotonin reuptake inhibitors may well be selected as first line treatments for many elderly depressed subjects.