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Initial Choice of Antidepressant Therapy in Primary Care-Reply

Gregory E. Simon, MD, MPH; Michael VonKorff, ScD; Louis Grothaus, MA; Edward Wagner, MD, MPH; John Heiligenstein, MD; Dennis Revicki, PhD
JAMA. 1996;276(16):1302. doi:10.1001/jama.1996.03540160024026.
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In Reply.  —We agree with Dr Bruhat and colleagues that our findings may not necessarily generalize to older primary care patients. It is possible that adverse effects of TCAs might prove more problematic in the elderly. Our sample of elderly patients was not large enough to permit subgroup analyses.Dr Schwab raises a question not addressed in our study. While SSRI drugs are less toxic in overdose, our sample was not large enough to examine differences in morbidity, mortality, or cost attributable to suicide attempts. It is unlikely that any randomized trial will ever allow the statistical power necessary to address this question.The antidepressant cost information Schwab presents may not reflect the actual costs of prescribing. The "true" cost of initial antidepressant selection must reflect the complexity of actual antidepressant use (eg, medication switches, early discontinuation, or dosage actually consumed). Cost projections based on per-pill prices also require assumptions about "equivalent"


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