Choosing between SSRIs and TCAs.

I n the article " Pharmacologic treatment of depression in late life " Alastair Flint gives a thorough and comprehensive review of the treatment of depression. He mentions that to his knowledge, " only 1 trial has compared an SSRI [selective serotonin reuptake inhibitor] (sertra-line) with a secondary amine TCA [tricyclic antidepressant] (nortripty-line), and both drugs were equally well tolerated. " However, he fails to include the results of 2 recent ran-domized controlled trials that have examined this question. The first was a 12-week, double-blind, randomized placebo-controlled trial comparing the efficacy of sertraline with that of imipramine in the treatment of depression. 1 Eighteen percent of patients taking imipramine discontinued their medication because of adverse effects, whereas only 6% of those taking sertraline and 4% of those receiving a placebo did so. This 14% absolute risk increase (18% – 4%) means that 1 in every 7 patients (100/14) taking imipramine for 12 weeks but only 1 in 50 patients (100/2) taking sertraline for the same period will experience an adverse effect. The second study examined the cost and the clinical efficacy of fluox-etine relative to those of imipramine and desipramine. 2 The proportion of patients who discontinued their medication before the 1-month assessment because of adverse effects was significantly lower among those taking fluoxetine (9%) than among those taking desipramine (27%) or imipramine (28%). Although there is sufficient anec-dotal evidence suggesting that SSRIs may have a lower adverse effect profile than TCAs, the scientific evidence behind this claim is not overwhelming. However, the results of these 2 trials, along with previous findings, 3 suggest that SSRIs should be used to treat depression in patients who cannot tolerate TCAs because of adverse effects, especially elderly patients. A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia. al. Initial antidepressant choice in primary care. Effectiveness and cost of fluoxetine vs tricyclic antidepressants.tive serotonin reuptake inhibitors: meta-analysis of efficacy and acceptability. I n my review I noted that the secondary amine TCAs nortriptyline and desipramine are less likely to induce side effects than the tertiary amine drugs such as amitriptyline and imipramine. Therefore, when a TCA is given to an elderly person, it is preferable to use a secondary amine drug. I also noted that there is no evidence from controlled trials that elderly patients tolerate SSRIs better than secondary amine TCAs. In all published studies comparing the effects …