Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
To the Editor: Dr Reynolds and colleagues1 concluded that nortriptyline, a tricyclic antidepressant, was superior to placebo in the treatment of major depression in older patients. Our study in older patients reached the same conclusion.2 We used lofepramine, a prodrug of nortriptyline, in our study because it has less anticholinergic activity and is more suitable for older patients. Lofepramine is available in western Europe but not in the United States. We found that patients with minor depression also responded to the placebo.
In the study by Reynolds et al, nortriptyline was titrated to a plasma steady-state level of 80 to 120 ng/mL. While this approach may be desirable in younger adults, it may not always be necessary in older adults. In our study, older patients with major depression responded to one third the recommended dose, ie, 70 mg per day. By and large, this practice is safer for older adults, especially because of the potential anticholinergic adverse effects of tricyclic antidepressants.3 - 4 For the few patients who do not respond to the low dose, it can then be adjusted appropriately. Anticholinergic adverse effects such as blurred vision, urinary retention, constipation, and confusion can be prevented in older patients. The adage of "start low, go slow" holds true for administration of tricyclic antidepressants to older patients.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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