The use of antidepressants in the elderly: 1986 and 1989

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.