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Apr 30, 1988 - methods: the first part of the Nottingham health profile2; the list of ... subjects had a history of at least two episodes of depression and were.
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BRITISH MEDICAL JOURNAL

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OBSERVED

Practice Research

Antidepressant drugs in the elderly: Are the indications term as the treatment?

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ANTHONY J DUNCAN, A JOHN CAMPBELL Abstract In a community study of 761 people aged 70 years and over 45 (5 9%) were found to be taking long term tricyclic antidepressants. Forty four were compared with matched controls. There was no evidence that tricyclic antidepressants were being used to compensate for poor physical health or function. Twenty subjects had a clear history of depression; three of these required additional treatment and five might have coped without continued drug treatment. Twelve of the remainder had started treatment with tricyclic antidepressants as hypnotics and 11 as a trial because of suspected depression. They had continued taking the drugs over a long period. Regular review of both the adequacy of and the necessity for continued treatment with tricyclic antidepressants in the elderly is recommended.

Introduction There are problems associated with the long term use of psychotropic drugs. Most attention has been directed to the neuroleptics because they may induce tardive dyskinesia and to the benzodiazepines because of the problems of abuse and dependence associated with these drugs. Less attention has been paid to the long term use of tricyclic

Departments of Psychological Medicine and Medicine, University of Otago Medical School, Dunedin, New Zealand ANTHONY J DUNCAN, MB, FRANZCP, clinical lecturer in psychogeriatrics A JOHN CAMPBELL, MD, FRACP, professor of geriatric medicine Correspondence to: Professor A John Campbell, University of Otago Medical School, PO Box 913, Dunedin, New Zealand.

antidepressants. This may be because there is, as yet, no well documented evidence of long term complications caused by these drugs. In the elderly, however, their anticholinergic activity, propensity to cause postural hypotension, and effects on cardiac conduction can produce serious side effects. ' We investigated a sample of people aged 70 years and over who had been taking tricyclic antidepressant drugs for at least one year. The purposes of this study were to determine the factors that distinguished those undergoing long term treatment with antidepressants from controls matched for age and sex and to determine the reasons for starting and continuing treatment.

Patients and methods Mosgiel is a rural township of 13500 people situated just south of Dunedin, New Zealand. The town is served by five general practitioners based at the Mosgiel Health Centre. Figures from the electoral roll showed that 94% of people living in the area were registered with the health centre. The names, ages, and addresses of all people aged 70 years and over were drawn from the records of the health centre. These 825 people were asked to cooperate in a longitudinal study, and 761 (92%) agreed to participate. None of those who refused was taking tricyclic antidepressants. At the initial interview the research nurse inspected and recorded all drugs being taken by the subjects. Forty five (5-9%) were taking antidepressant drugs, all tricycic antidepressants. At the end of one year all of these patients were still taking these drugs; they were thus used as the sample for this study. A control sample of subjects matched for age (within five years), sex, and general practitioner was drawn from the health centre records. One subject who was taking tricyclic antidepressants withdrew from the study. The remaining subjects and controls completed the investigations. Each participant was seen on two occasions, first by the research nurse and then by AD, who was initially unaware whether the participant was a subject or a control. At the first visit participants were assessed by the following methods: the first part of the Nottingham health profile2; the list of threatening life experiences3; and the activities of daily living questionnaire.4 At the second interview participants completed the 28 item version of the general health questionnaire5-7 and a brief test of cognitive function (the mini

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mental state examination).8 Each participant's psychiatric state was assessed clinically. The participants were then asked to show drugs that they were currently taking. Those subjects taking tricyclic antidepressants were further interviewed to assess their psychiatric history, whether they thought that they benefited from the drug, and how they viewed its continued use. The psychiatric interviews and inspection of the general practitioner's notes were used to determine the reasons for starting and continuing treatment with tricyclic antidepressants. The Wilcoxon signed rank test for paired samples was used to compare scores in the subject and control groups. The Mann-Whitney U test was used to compare treatment scores between the subgroups taking tricyclic antidepressants. The dosage of the drugs was calculated by assuming all tricyclic antidepressants to be of equal potency. The study was approved by the ethical committee of the University of Otago Medical School and the Otago Hospital Board.

The table shows the scores of the subjects and controls in the tests administered. Only with the Nottingham health profile was there a significant difference between all the subjects and controls, with the subjects having a lower subjective health state. This difference was still significant (p