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To the Editor: Dr Reynolds and colleagues¹ concluded that nortriptyline, a tricyclic antidepressant, was superior to placebo in the treatment of major depression in older patients. Our study in older patients reached the same conclusion.² We used lofepramine, a prodrug of nortriptyline, in our study because it has less anticholinergic activity and is more suitable for older patients. Lofepramine is available in western Europe but not in the United States. We found that patients with minor depression also responded to the placebo.

In the study by Reynolds et al, nortriptyline was titrated to a plasma steady-state level of 80 to 120 ng/mL. While this approach may be desirable in younger adults, it may not always be necessary in older adults. In our study, older patients with major depression responded to one third the recommended dose, ie, 70 mg per day. By and large, this practice is safer for older adults, . . . [Full Text of this Article]