Choosing between SSRIs and TCAs CMAJ 1998;158:469 See response from: A. Flint. In the article: "Pharmacologic treatment of depression in late life" (CMAJ 1997;157[8]:1061-7 [full text/résumé]), Dr. 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] (sertraline) with a secondary amine TCA [tricyclic antidepressant] (nortriptyline), and both drugs were equally well tolerated." However, he fails to include the results of 2 recent randomized 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 fluoxetine 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 anecdotal 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. Mahyar Etminan, BScPharm, Rph Student Department of Pharmacology and Therapeutics University of British Columbia Vancouver, BC MEtminan@aol.com References Thase ME, Fava M, Halbreich U, Kocsis JH, Koran L, Davidson J, et al. A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia. Arch Gen Psychiatry 1996;53:777-84. Simon GE, VonKorff M, Heiligenstein JH, Revicki DA, Grothaus L, Katon W, et al. Initial antidepressant choice in primary care. Effectiveness and cost of fluoxetine vs tricyclic antidepressants. JAMA 1996;275:1897-902. Song F, Freemantle N, Sheldon TA, House A, Watson P, Long A, et al. Selective serotonin reuptake inhibitors: meta-analysis of efficacy and acceptability. BMJ 1993;306:683-7. Send a letter to the editor responding to this article Envoyez une lettre à la rédaction au sujet de cet article | CMAJ February 24, 1998 (vol 158, no 4) / JAMC le 24 février 1998 (vol 158, no 4) |