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Letter to the editor
Editor, – I would like to respond to Associate Professor Evans' concluding remarks (Aust Prescr 1993;16:59-60) regarding the new reversible MAO-A inhibitor moclobemide. He suggests tricyclics (TCAs) should be 'the treatment of first choice for most patients with major depressive disorder' and that TCAs 'are effective and safe when (my emphasis) used properly and we know (my emphasis) how to use them properly'. Hence, he suggests moclobemide occupies a second order or lesser status.
In 1990, 386 Australians (source: ABS) died by suicide by ingestion of solid and liquid substances. A Brisbane survey of overdose fatalities1 suggests that TCAs account for about 10% of these suicides (i.e. 10% of 386). Hence, TCAs kill about 38 Australians a year by over dosage alone. Professor Evans gives brief mention of the overdose issue which does not do justice to this mortality nor the reality that depression is associated with more than 50%of all suicides (all methods). Saying that TCAs are 'safe when used properly' reminds me of the outmoded attitudes of the motor vehicle industry - that cars are safe when driven properly! Also, we do not know how to use TCAs properly for the simple reason that the ability of psychiatrists (not to mention others) to predict which patients will overdose is dismal.
I suggest that in considering which antidepressants to use, the potential for overdose is a vital consideration. As we cannot reliably predict suicide, I advocate that the newer less toxic antidepressants should be first-line drugs in patients at significant risk. I say this acknowledging the hazard of the unknown associated with new drugs (e.g. zimelidine and nomifensine - 'new' antidepressants which were subsequently withdrawn). In my opinion, tricyclics generally maybe first-line drugs in those patients who one is confident will not overdose.
Dr Chris Cantor
Suicide Research and Prevention Program
Princess Alexandra Hospital
- Cantor CH. Substances involved in fatal drug overdoses in Brisbane, 1979-1987. Acta Psychiatr Scand 1989;80(354 Suppl):69S-71S.