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Antidepressant Use in Patients Prescribed β-Blockers

David J. Graham, MD, MPH; Frank E. Lundin, MD, DrPH; Franz Rosa, MD, MPH; Carlene Baum, PhD
JAMA. 1986;255(23):3249. doi:10.1001/jama.1986.03370230054023.
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To the Editor.—  We read with interest the article by Avorn et al1 showing an increased prevalence of tricyclic antidepressant (TCA) use among patients ever receiving β-blockers, compared with selected antihypertensive and antidiabetic drugs. This may be consistent with the labeling as shown in the Physician's Desk Reference, which lists depression as a possible side effect of β-blockers use. Our experience with the Medicaid data base used in this study leads us to raise three concerns about the methodology employed, as they represent potential sources of bias in the study that collectively may serve either to underestimate a real association or generate a spurious one.1. The study design used does not distinguish which came first, the "exposure" (eg, β-blockers or hydralazine use) or the "outcome" of interest (TCA use), and hence does not examine directly the underlying question of temporal relationship between the two. Although we do not

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