Controlled withdrawal of selective serotonin reuptake inhibitors in elderly patients in nursing homes with no indication of depression—a commentary

Recent investigations performed by the Swedish National Board of Health and Welfare have indicated that as many as 40% of the elderly in nursing homes are on anti-depressive drugs, mainly modern selective serotonin reuptake inhibitors (SSRIs) such as citalopram and sertraline. These studies have also shown that in many cases SSRI treatment is administered without a correct indication, and therefore one quality indicator of medicine use in the elderly [1, 2] is the percentage of patients on SSRI treatment without a correct indication. Increasing the quality of medication in nursing homes is a humane, social, and medical priority and any study aimed at this goal should be encouraged. We have read with great interest an article published by Ulfvarson et al. [3]. The study—directed by Christer von Bahr—was an open, randomized, non-placebo controlled clinical trial aimed at investigating the effects of withdrawal of SSRIs in elderly nursing home patients with no documented diagnosis or symptoms of depression. Of a total of 350 patients on SSRI treatment from 11 nursing homes in the county of Stockholm, Sweden, 70 patients aged 75 years or older with no current depressive symptoms and no history of depression or anxiety and who were taking citalopram or sertraline for at least 6 months met the inclusion criteria and consented to participate. Patients were randomized to either intervention (withdrawal of SSRI) or the control group (no change in treatment). According to the authors, the main outcomes were standardized measures of depression, global functioning, and health. After 6 months of follow-up, the authors found no significant difference between the intervention and control groups in any outcome measure. The authors concluded that treatment with SSRIs in patients without major clinical depression or anxiety disorder is often unjustified and should be discontinued. The conclusion of this investigation seems to confirm the established indications for withdrawing SSRI treatment in elderly patients [1]. Unfortunately, the study contains so many flaws in both design and analysis, which make it an unacceptable source of evidence. The authors seem to be unaware on any guidelines for good clinical trial practice or recommendation for publication of clinical trials as the CONSORT statement, which is a relevant research tool to improve the quality of reports of randomized trials [http:// www.consort-statement.org/]. In general many aspects of the trial [2] lack transparency, which makes it difficult to understand how the trial was designed, conducted, and analyzed.