Guidelines for treating depressive illness with antidepressants: A statement from the British Association for Psychopharmacology.

Depression is a common illness which affects some 3% of the population per year. At least 25% of those with marked depression do not consult their general practitioner and in half of those who do the illness is not detected. Depression is easy to recognize when four or five of the core symptoms have been present for 2 weeks which often coincides with some occupational and social impairment. The core symptoms are depressed mood, loss of interest or pleasure, loss of energy or fatigue, concentration difficulties, appetite disturbance, sleep disturbance, agitation or retardation, worthlessness or self blame and suicidal thoughts. A diagnosis of depression is made when five of these core symptoms, one of which should be depressed mood or loss of interest or pleasure, have been present for 2 weeks. Four core symptoms are probably sufficient. Response to antidepressants is good in those with more than mild symptoms. When there are only few or very mild depressive symptoms evidence of response to antidepressants is more uncertain. Antidepressants are effective, they are not addictive and do not lose efficacy with prolonged use. The newer antidepressants have fewer side effects than the older tricyclics, they are better tolerated and lead to less withdrawals from treatment. They are less cardiotoxic and are safer in overdose. Antidepressants should be used at full therapeutic doses. Treatment failure is often due to too low a dose being used in general practice. It may be difficult to reach the right dose with the older tricyclics because of side effects. To consolidate response, treatment should be continued for at least 4 months after the patient is apparently well. Stopping the treatment before this is ill-advised as the partially treated depression frequently returns. Most depression is recurrent. Long-term antidepressant treatment is effective in reducing the risk of new episodes of depression and should be continued to keep the patient well.

The elderly depressed and treatment with fluvoxamine.

Depression is highly prevalent in the elderly and there are difficulties with definition and diagnosis. The signs and symptoms of depression may differ from those in younger patients since the elderly are frequently preoccupied with physical ailments and may have more agitation, insomnia and hypochondriasis. The aetiology and cause of depression and its association with psychosocial and other risk factors are discussed, with particular reference to masked depression, depressive delusional illness and 'pseudo dementia'. A range of treatments have been used in depressive patients, including psychotherapy, cognitive therapy, ECT and various drug treatments. In the elderly drugs may cause more problems than in younger patients. These can be divided into those associated with: pharmacokinetics, polypharmacy, side effects, dosage and lethality. Trials of antidepressants in the elderly are discussed and include trials with tricyclic antidepressants, monoamine oxidase inhibitors and SSRIs. Particular reference is made to a trial of fluvoxamine versus mianserin in the elderly, which demonstrated that fluvoxamine is as effective as mianserin in treating depression, and has fewer side effects.

Double-blind comparative multicentre study of fluvoxamine and mianserin in the treatment of major depressive episode in elderly people.

This is a multicentre double-blind study of fluvoxamine versus mianserin in the treatment of major depressive episode in patients over 65 years of age. Fifty-seven patients received either fluvoxamine (100-200 mg daily) or mianserin (40-80 mg daily). There was no statistically significant difference in improvement between the 2 treatment groups as measured by the Montgomery-Asberg Depression Rating Scale. Eleven patients (7 in the fluvoxamine group and 4 in the mianserin group) discontinued treatment because of intolerance. No statistically significant differences were seen in biological parameters with either drug. Both drugs improved the symptoms of depression though the overall response rate was not outstanding. The side effects profile for the fluvoxamine was contrary to previous studies in that frequent nausea and vomiting were not seen.

Remoxipride versus thioridazine in elderly psychotic patients.

A total of 18 hospitalized elderly psychotic patients in need of antipsychotic treatment took part in a double-blind exploratory study concerning the safety, tolerability and efficacy of remoxipride and thioridazine. Their median age was 78 years (range 66-90 years). Over the study period of 6 weeks, 9 patients received remoxipride and 9 thioridazine. Both drugs were given in a dosage range of 50-200 mg/day. The median total score on the Brief Psychiatric Rating Scale at the start of active treatment was 18 in the remoxipride group and 24 in the thioridazine group. The scores were reduced to 6 and 7, respectively, at the last rating. The Clinical Global Impression at last rating showed 4 of the 9 remoxipride patients to be very much improved compared to 1 of the 9 thioridazine patients. Apart from three reports of severe drowsiness in the thioridazine group, the incidence of treatment-emergent adverse effects was low in both groups. No clinically significant aberrations were seen in laboratory tests or cardiovascular data. In conclusion, remoxipride seemed to be well tolerated in this group of patients and its antipsychotic efficacy in the doses used is promising.

Geriatric psychiatry manpower--seven services in Scotland.

The method of calculating district psychiatric manpower described by Watson was applied to seven geriatric psychiatry services in Scotland serving a population of 1,445,000 including 209,600 individuals over the age of 65 years of age. The overall medical staffing of these services was only 63.6% of the estimated requirement and when individual consultants were considered only 62% of the necessary time was available. If it is assumed that half of the extra medical time should be provided by consultants, then 3.2 consultant WTEs will be needed for geriatric psychiatry for a population of 200,000 with 30,000 elderly people. If there was no change in the proportion of medical work provided by consultants, the figure would be 2.9 consultant WTEs per 30,000 population aged over 65 years. Extra supporting staff are also required to meet the requirements of the Watson formula.