Intended for healthcare professionals

Rapid response to:

Editorials

New antidepressants for old people?

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7199.1640 (Published 19 June 1999) Cite this as: BMJ 1999;318:1640

Rapid Response:

Efficacy and clinical effectiveness

Dear Sir,

Having quite rightly criticised the various studies on efficacy and
drop-out rates on the basis of the fact that all the trials excluded
subjects with physical disorders, Livingston and Livingston then proceed
to offer advice based on these (and other) similarly flawed studies.

I know of no practising clinician who prescribes placebo, and it is
unethical to run clinical trials where people are prescribed placebo and
so denied active treatments which have already shown their superiority
over placebo. Also, is there any way of predicting, with any certainty,
which older people are "at risk of taking an overdose"?

For those who still need more evidence (and I do not), perhaps we
need relevant non-placebo comparator trials on 'real' patients, with no
exclusion parameters applied.
Also, there is a need to distinguish between efficacy in an artificially
contolled trial setting and clinical effectiveness as demonstrated in real
practice where there is increasing evidence that patients are far more
likely to be concordant with medication for the appropriate treatment
length. It is also evident from studies of GP prescribing that doses of
tricyclics are also prescribed at woefully sub-optimal doses.

Until further data are available, all primary care physicians (who
deal with 90-95% of this group of patients) should be recommended to use
newer antidepressants first line. Secondary care physicians, who now spend
most of their time dealing with psychoses and schizophrenia, are possibly
no longer the best arbiters and advisors on this subject.

In the end, ease of prescribing an effective clinical dose from day
one and near zero toxicity will decide this issue and I cannot see any
justification in 1999 for continuing to prescribe any drug where there is
a "high risk of death" by any method under any circumstance; in the case
of a tricyclic, this can often be very close to the therapeutic one anyway

Doctors who are prepared to prescribe lethally are to be
congratulated on their stamina, but, in the coroner's court, it is
doubtful whether those who issue such guidelines will be there to proffer
any succour.

Yours Faithfully
Dr. Chris Manning MRCGP

Conflict of interest: I have depression; took a tricyclic for eight
years and have been on an SSRI for six. Most of the depressed doctors I
know, having taken a newer antidepressnat would not go back onto an older
one - perhaps that would be a good study; together with what would you
prescribe you granny?

Competing interests: No competing interests

19 June 1999
Chris Manning
GP
Teddington