Abstract
Ellen Beerworth, Sydney, Australia and John Tiller, Melbourne, Australia:
In their recent article, ‘The place for the tricyclic antidepressants in the treatment of depression’ Philip Boyce and Fiona Judd [1] refer to our recent paper, ‘Liability in prescribing choice: the example of the antidepressants’ [2] as arguing that the older tricyclic antidepressants (TCAs) should no longer be considered for first-line treatment (for depression). This grossly misrepresents our paper, and the arguments we made in it. Our paper did not purport to be a definitive comparison of the merits or otherwise of particular agents, nor did we make recommendations about prescribing specific classes of antidepressants.
Our paper stated: ‘There needs to be compelling reasons for prescribing medicines with a greater likelihood of adverse outcomes such as older antidepressants (e.g. tricyclics) rather than the newer antidepressants such as RIMAs, SSRIs, SNRIs and 5HT2 receptor antagonists. The higher likelihood of an adverse outcome of treatment where an older antidepressant has been prescribed raises the potential for professional negligence claims to be brought against medical practitioners who prescribe such medicines for reasons other than established medical need.’
It further stated: ‘Comparative toxicity, tolerability and efficacy should be considerations when initiating therapy, where therapy must be changed following relapse, where there are tolerability problems, or increased suicide risk, or where the patient is ageing so that previously tolerated side-effects become intolerable, such as increasing urinary difficulties with advancing age being exacerbated by a TCA…’
Later it stated: ‘In the event of a professional negligence claim a medical practitioner may be called upon to show a compelling reason for the prescribing choice if they have, for example, prescribed a TCA to a patient at risk of suicide, or to a cardiac patient when a TCA would be contraindicated, or where there are disabling side-effects that are less likely with another agent, or have prescribed at subtherapeutic doses.’
Our paper concluded: ‘Given the proven efficacy and tolerability of the newer antidepressants, cases in which there is a genuine medical need for the prescription of a TCA as the initial choice of therapy might be expected to be rare’.
Our arguments were not that TCAs should no longer be considered first-line treatment, but rather that, when choosing to prescribe any agent, a prescriber should be mindful of potential liabilities, especially where there are alternative therapies available that have proven lower toxicity and proven comparable efficacy and higher tolerability.