Tolerability of selective serotonin reuptake inhibitors: issues relevant to the elderly.

Selective serotonin reuptake inhibitors (SSRIs) continue to be the first-choice antidepressant treatment for the elderly as they have similar efficacy to other antidepressants but better tolerability. However, recent concerns have emerged regarding a range of adverse effects that are more likely to occur in the elderly. In part this relates to the increased risk of drug interactions. Platelet dysfunction induced by SSRIs with high serotenergic activity is associated with gastrointestinal bleeding in the first month of treatment, although the overall evidence is weak. The risk of falls and fractures in elderly patients taking SSRIs is similar to that reported with use of tricyclic antidepressants. Hyponatraemia due to induction of the syndrome of inappropriate antidiuretic hormone secretion may be life threatening in the elderly but in most cases is asymptomatic and reversible. Extrapyramidal disorders such as parkinsonism and dyskinesias are more common in the elderly but are rare. There is a very low risk of cerebrovascular adverse reactions in patients taking SSRIs. There are inconsistent findings linking SSRIs with suicidal behaviour in late life and with the risk of cancer. Most of the newly identified adverse effects are either relatively uncommon or of debatable significance. Few differences have been identified among the SSRIs that are of clinical significance. However, it is recommended in the elderly that SSRIs should be titrated slowly to recommended therapeutic doses and used cautiously with other agents known to have the potential for drug interactions.