Initial Choice of Antidepressant Therapy in Primary Care

To the Editor.  —The conclusion reached by Dr Simon and colleagues¹ in their article comparing imipramine, desipramine, and fluoxetine as initial antidepressant choices in primary care was surprising. They stated, "Because clinical outcomes, quality-of-life outcomes, and treatment costs provide no clear guidance, patients' and physicians' preferences are an appropriate basis for treatment selection." There are additional relevant and critical considerations that the primary care physician must use. These include the safety of the antidepressant in overdose, the adverse effect profile that permits greater compliance, and the ease with which an effective therapeutic dosage can be achieved.McFarland² compared the selective serotonin reuptake inhibitor (SSRI) paroxetine with the TCA imipramine. He found, as did Simon et al, that the higher tablet cost of the SSRI was offset by the costs of the frequent physician visits to adjust dosage and monitor adverse effects as well as the higher dropout rate in the imipramine