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03 02/09/2002 3 14 pm Page 43 Co-morbid depression 43 were not depressed. A study of clomipramine 25–100 mg in patients with dementia and depression or dysthymia found that, although clomipramine had superior efficacy as measured by the response of depressive symptoms, it had a mild adverse effect on cognition. There have been some head-to-head trials of antidepressants in this field. In the first two, groups of patients responded well on depression scales to citalopram 20–40 mg/day and mianserin 30–60 mg/day for 12 weeks.

Most other published trials have lacked placebo control, and there is insufficient RCT evidence for the efficacy of the newer agents, such as SSRIs, in the long-term treatment of depression overall. The exception is citalopram 20–40 mg which in a placebo controlled trial in responders at 8 weeks reduced the rates of recurrence from 68% to 32% over a 48 week period. None of the patients on 20 mg citalopram experienced a recurrence, (Klysner et al, 2001) There is, however, consistent open trial evidence that TCAs and SSRIs have similar prophylactic effects.

Their active drug was the SSRI fluoxetine. The outcome in this study was that the difference in response rates (64% with fluoxetine, 38% with placebo) just failed to reach statistical significance. Post-hoc analyses showed fluoxetine to be significantly superior in those who completed 5 weeks of treatment and in those with more severe physical illnesses. 03 02/09/2002 3 14 pm Page 45 Co-morbid depression 45 depression and heart disease; the mean age of the patients was 70. Response to nortriptyline was significantly better than that to fluoxetine (67% vs 23%).

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