Don't forget MAOl's and tricyclics Currently there is no single drug of choice and

no concrete direction for the treatment of depression. In the past, tricyclics were first choice agents with either MAOIs or electroconvulsive therapy as second choice. 'Treatment resistant' patients received combination therapy or unconventional remedies, which were not very successful. Dr Rapp suggests that treatment­resistance ' ... "'lIS probably as much a result 0/ tile underuse 0/ existing drugs lIS it "'lIS an actual resistance to treatment'.

Over the last decade, trazodone and fluoxetine have become available for the treatment of depression. Buspirone was approved in 1990 for the indication of anxiety only, however, evidence of its usefulness in depression also exists. Louis Fabre stated, at the Ontario Medical Association convention in June 1990, that combinations of these 3 agents is, or would be, the therapy of choice in depression and that tricyclics and MAOIs would become obsolete.

Dr Rapp argues that there are many reasons for utilising older agents, rather than newer agents, in the initial treatment of depression: • The adverse effects of tricyclics can be

reduced by beginning with low doses and by increasing doses slowly;

• it is possible to measure the serum levels of tricyclics, whereas this is not possible for fluoxetine and buspirone;

• the newer agents are expensive; • the new concept of lithium augmentation of

tricyclics or MAOIs and thyroid augmentation of tricyclics improve the success of these agents.

Rapp MS. Antidepressants: too many choices? Canadian Journal of Psychiatry 36: 615-616, Oct 1991 .. "

1 23 No, 1991 INPHARMA- ISSN 0156-2703/91/1123-0002/0$01.00/0 0 Ad" llllmlllliolllll Ltd