No abstract

We studied the following questions: (1) Do physicians preferentially prescribe antidepressants (ADs) with the least side effects (SEs) of sedation, orthostatic hypotension, and anticholinergic activity; (2) Have there been any recent changes in prescribing patterns; and (3) Do patterns differ for psychiatrists and nonpsychiatrists. Data on psychiatrist and non-psychiatrist outpatient prescribing of specific ADs were obtained from the National Prescription Audit (NPA) for 1986 and 1989. In 1986, physicians did not minimize the use of ADs with the most of these SEs. The 1989 data indicate that psychiatrists made a major change toward prescribing more low SE ADs and less ADs with the most SEs. The data for nonpsychiatrists also suggest some movement in this direction. The availability of fluoxetine and the concomitant focus on SEs may have contributed to this shift. Further investigation is needed to clarify factors that influence physicians' choices of ADs.

Depression is a frequent disorder in the elderly that is often treated with antidepressants. It is generally accepted that, since all antidepressants are equally effective and the elderly are differentially more susceptible to side effects, those antidepressants with the least side effects should be preferentially used. The actual use of antidepressants in 1986 and 1989 was reviewed. We found that (1) contrary to expectation, antidepressants were prescribed in 1986 in quantities that were directly proportional to their side effects, ie, the greater the side effects, the more they were used, and (2) there was a distinct shift to a more thoughtful pattern in 1989. After reviewing the side effect profiles of antidepressants, it is recommended that amitriptyline and doxepin be avoided and that the initial choice be restricted to desipramine, nortriptyline, fluoxetine, and possibly bupropion. This simple change would reduce the relatively high rate of falls and fractures from antidepressant-induced hypotension and of delirium in the elderly. It would also promote increased compliance and greater efficacy, since larger doses will be tolerated.