Depression affects as many as 40% of adults older than 55 years,1 and major depressive disorder leads to substantial disability,2 with an estimated US societal cost of $83.1 billion in the year 2000.3 In the past 2 decades, second-generation antidepressants in the family of selective serotonin reuptake inhibitors (SSRIs) have vastly surpassed first-generation tricyclic antidepressants (TCAs) in the marketplace and now rank third among all drug classes in US prescription drug sales.4 The SSRIs have similar efficacy to TCAs in improving quality of life and decreasing mortality among depressed adults.4 Preference for SSRIs over TCAs has been driven by a lower risk of anticholinergic adverse effects and overdose lethality. Because of concerns about the arrhythmogenic potential of TCAs, there is a strong preference for SSRIs in older adults in whom depression commonly coincides with heart disease.5 Despite controversy about increased suicidality in children,6 SSRIs have continued to grow in popularity and have been largely devoid of other serious safety concerns, at least so far.
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