I am writing to complain about the article ‘Choosing an antidepressant’.1 The article did not define mild–moderate depression and did not mention screening patients to exclude an organic cause of the depression. It mentioned agitated depression, but not that agitation suggests a mixed state that would be worsened by antidepressants.

Sexual adverse effects are a significant problem with antidepressants, but the article only recommended agomelatine to minimise these effects. Mirtazapine, moclobemide, reboxetine, vortioxetine and bupropion all have favourable adverse-effect profiles. Agomelatine is an antidepressant produced by Servier and one of the authors has received payments from that company. It is not enough that authors declare their conflicts of interest. They should avoid publishing articles that could be perceived to be influenced by payment.

Andrew Nielsen 
Psychiatrist, Toowong, Qld


Authors' response

Philip Boyce and Cassandra Ma, the authors of the article, comment:

We thank Dr Nielsen for his comments. While we agree that we did not define mild–moderate depression, we assumed most GPs would understand the term. We later stated that antidepressants are indicated for depressed patients with marked symptoms and functional impairment.

Screening patients for an organic cause for depression is important and we hope this would be part of routine practice. However, Australian Prescriber commissioned us to write about choosing an antidepressant, not the assessment of patients with depression.

Agitated depression can indicate a ‘mixed state’,2,3 and the possibility of bipolarity (a history of a manic episode) should be examined in any patient presenting with an agitated depression. However, our article was referring to the more common situation in which an agitated depression is not part of a bipolar illness.

Sexual adverse effects are a significant problem and we included them when we rated the limitations of the classes of antidepressants. These ratings were based on our review of the literature and gauging the opinion of experts (the mood disorders guideline working party3) using a Delphi process. Minimum limitations are found with moclobemide, mianserin and agomelatine, while reboxetine, mirtazapine and vortioxetine are rated as having more limitations. We suggested that agomelatine be used for patients with sexual dysfunction based on its efficacy and very low reported levels of sexual dysfunction.4


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Andrew Nielsen

Psychiatrist, Toowong, Qld

Philip Boyce

Professor of Psychiatry, Specialty of Psychiatry, Westmead Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney

Cassandra Ma

Research assistant, Specialty of Psychiatry, Westmead Clinical School, Sydney Medical School, Faculty of Medicine and Health, University of Sydney