Rationalizing antidepressants for elderly people.

A rational approach to the use of antidepressants in the elderly must consider the evidence as to whether such treatment is efficacious (in controlled trials) and effective in clinical practice. Effective treatment of depression depends on its detection, and the subsequent initiation and continuation of adequate treatment. There is considerable evidence for both under-detection and under-treatment of depression in old age. Choice of antidepressant will be influenced by patients' fitness for treatment and by drug side effect profile, with postural hypotension and confusion being particular risks associated with tricyclics. The advantages of newer antidepressants (simple regimen, starting dose usually adequate, good safety profile, fewer contraindications) are likely to be more evident clinically than in controlled trials. Full economic evaluation requires data on the direct and indirect costs of depression in old age and on costs of treatment failure; many of these data are lacking.