Thapa P B, Gideon P, Cost T W, Milam A B, Ray W A
Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
N Engl J Med. 1998 Sep 24;339(13):875-82. doi: 10.1056/NEJM199809243391303.
In nursing home residents, the use of tricyclic and other heterocyclic antidepressants is associated with an increased risk of falls. The newer selective serotonin-reuptake-inhibitor antidepressants are largely free of the side effects of the tricyclic agents thought to cause falls and so have been hypothesized to be safer for those at high risk for falls.
We retrospectively identified an inception cohort of 2428 nursing home residents in Tennessee who were new users of tricyclic antidepressants (665 subjects), selective serotonin-reuptake inhibitors (612 subjects), or trazodone (304 subjects) or nonusers of antidepressants (847 subjects). We ascertained the number of falls during therapy and during a similar follow-up period for nonusers, then calculated the rate ratios for falls with adjustments for an extensive set of potential confounding factors.
The new users of each type of antidepressant had higher rates of falls than the nonusers, with adjusted rate ratios of 2.0 (95 percent confidence interval, 1.8 to 2.2) for tricyclic antidepressants, 1.8 (1.6 to 2.0) for selective serotonin-reuptake inhibitors, and 1.2 (1.0 to 1.4) for trazodone. The rate ratios increased with the daily dose for tricyclic antidepressants, reaching 2.4 (95 percent confidence interval, 2.1 to 2.8) for doses of 50 mg or more of amitriptyline or its equivalent, and for the serotonin-reuptake inhibitors, reaching 1.9 (1.7 to 2.2) for 20 mg or more of fluoxetine or its equivalent. The elevated rates of falls persisted through the first 180 days of therapy and beyond.
In this large study of nursing home residents, there was little difference in rates of falls between those treated with tricyclic antidepressants and those treated with selective serotonin-reuptake inhibitors. Hence, the preferential use of the newer antidepressants is unlikely to reduce the higher rate of falls among nursing home residents taking antidepressants.
在疗养院居民中，使用三环类及其他杂环类抗抑郁药会增加跌倒风险。新型选择性5-羟色胺再摄取抑制剂抗抑郁药基本没有被认为会导致跌倒的三环类药物的副作用，因此据推测对跌倒高风险人群更安全。
我们回顾性确定了田纳西州2428名疗养院居民的起始队列，这些居民分别是三环类抗抑郁药新使用者（665名受试者）、选择性5-羟色胺再摄取抑制剂使用者（612名受试者）、曲唑酮使用者（304名受试者）或非抗抑郁药使用者（847名受试者）。我们确定了治疗期间以及非使用者相似随访期内的跌倒次数，然后在对一系列潜在混杂因素进行校正后计算跌倒的率比。
每种抗抑郁药新使用者的跌倒率均高于非使用者，三环类抗抑郁药校正后的率比为2.0（95%置信区间为1.8至2.2），选择性5-羟色胺再摄取抑制剂为1.8（1.6至2.0），曲唑酮为1.2（1.0至1.4）。三环类抗抑郁药的率比随日剂量增加而升高，阿米替林或其等效剂量达50毫克或更高时，率比达到2.4（95%置信区间为2.1至2.8）；对于5-羟色胺再摄取抑制剂，氟西汀或其等效剂量达20毫克或更高时，率比达到1.9（1.7至2.2）。跌倒率升高在治疗的前180天及以后持续存在。
在这项针对疗养院居民的大型研究中，使用三环类抗抑郁药者与使用选择性5-羟色胺再摄取抑制剂者的跌倒率几乎没有差异。因此，优先使用新型抗抑郁药不太可能降低服用抗抑郁药的疗养院居民较高的跌倒率。
