Choosing between SSRIs and TCAs CMAJ 1998;158:469 Re: "Pharmacologic treatment of depression in late life" CMAJ 1997;157[8]:1061-7 [full text/résumé], by Dr. Alastair Flint. In response to: M. Etminan In 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 of an SSRI with those of a TCA in elderly patients, the TCA was a tertiary amine drug. Only one study, which was presented as a poster, involved a comparison between an SSRI and a secondary amine TCA, and both drugs were tolerated equally well.1 Etminan cites 2 studies to suggest that SSRIs are, in fact, better tolerated than secondary amine TCAs in the treatment of late-life depression. However, neither of the cited studies examined this issue. The first, by Thase and associates2 compared an SSRI with a tertiary amine TCA (imipramine) in young and middle-aged adults with dysthymia. The study by Simon and collaborators3 did include a secondary amine TCA (desipramine), but the median age of the subjects was 41 years and only 7% of the sample was aged 65 years or older. The findings of the second study cannot necessarily be extrapolated to elderly patients, who may be more sensitive to the adverse effects of SSRIs than younger patients. Furthermore, neither the patients nor the physicians in the study were blinded as to the type of antidepressant being prescribed, which may have influenced the rate of discontinuation of treatment. Compared with TCAs, SSRIs are safer, and there are fewer limitations to their use in elderly patients. However, secondary amine TCAs retain an important role in the treatment of late-life depression. To date, there is no evidence that, in appropriately selected elderly patients, secondary amine TCAs are less well tolerated than SSRIs. Alastair Flint, MB, ChB Associate Professor Department of Psychiatry University of Toronto Toronto, Ont. References McEntee WJ, Coffey DJ, Bondareff W, Alpert M, Raj AB, Rappaport SA, et al. A double-blind comparison of sertraline and nortriptyline in the treatment of depressed geriatric outpatients [poster]. American Psychiatric Assocation 148th annual meeting; 1995 May 20-25; Miami. 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. 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) |