850 CORRESPONDENCE mental state examination and, where indicated, a issue —¿wouldchanging to an SSRI be equally as physical examination or selective physical examin effective as adding one? One influential study (Nolen ation, and special investigations. This applies as eta!,1988)foundno benefitinchangingtofluvo much to people with Down's syndrome as it does to xamine for patients who were tricycic antidepressant the general population. non-responders, and is frequently cited to dismiss the We hope our papers help to establish that people strategy.However,a number ofotherauthorshave with Down's syndrome experience increased rates of found that a clinically significant proportion of tri certain psychiatric disorders, and that the pattern cyclic non-responders do respond to a subsequent of adaptive behaviour in these individuals changes SSRI given alone (Lingjaerde eta!, 1983; Delgado et with age. There is, of course, a distinction between al, 1988; Beasley et a!, 1990; White et a!, 1990). descriptive psychopathology by which a psychiatric Admittedly these have been open studies but I would diagnosis is made, and aetiological factors which argue that it is premature to dismiss changing to contribute to the described illness. Having estab another non-monoamine oxidase inhibitor anti lished different rates of psychiatric disorders, the depressant in favour of combination drug treatment next stage is to determine the relevant aetiological on current evidence. Further research is required factors. The view of Drs Prasher & Krishnan, that to determine the best ‘¿second-step'treatmentfor sensory impairment and medical illness account for patients failing to respond to an adequate trial of a the altered rates of psychiatric disorders, is specu tricyclic antidepressant drug. lative. We look forward with great anticipation to the publication of results from the Birmingham Down's Ba@[email protected],C.M., SAYLEIt,M.E., CUNNINGHAM,0.E., et al(1990) syndrome study to support their hypothesis. Fluoxetine in tricyclic refractory major depressive disorder. Journai of Affective Disorders, 20,193-200. @ Cg,@ppra, D. R., DALTON, A. J., SKoprrz, M., et al (1975) DELGADO, P. L., Pp@ca, L. H., D. S., et al(1988) Efficacy Alzheimer's degeneration in Down's syndrome: electrophysio of fluvoxamine in treatment-refractory depression. Journal of logical alterations and histopathology. Archivesof Neurology, 32, Affective Disorders, iS, 55—60. 618—623. LINGUERDE, 0., Bwi'os, 0., BL@mm, T., et al(l983) A double LAI, F. & WILLIAMS,R.S.(1989)A prospective study of Alzheimer's blind comparison of zimelidine and desipramine in endogenous disease in Down's syndrome. Archives of Neurology. 46,849-853. depression. Acta Psychiatrica Scandinavica. 68,22—30. REID, A. H. & AUNGL.E,P. 0. (1974) Dementia in ageing mental NoLEN, W. A., VAN DE PUrrs, 3. 3., DIGKEN, W. A., et al (1988) defectives: a clinical psychiatric study. Journal of Mental Treatment strategy in depression. 1. Non-tricycic and selective DeficiencyResearch. 18, 15—23. reuptake inhibitors in resistant depression: a double-blind partial —¿, MALONEY, A. F. J. & AUNGLE, P.O. (1978) Dementia in ageing cross-over study on the effects of oxaprotiline and fluvoxarnine. mental defectives: a clinical and neuropathological study. Journal Acta Psychiatrica Scandinavlca,78,668—675. of Mental DeficiencyResearch.22,233-241. WHITE,K., WYKoFF,W., TY1@1Es,L.L., et al(1990) Fluvoxamine in the treatment of tricyclic-resistant depression. Psychiatry Journal R. A. COLLACOTF of the University of Ottawa, 15, 156-158. S-A. Coo@iia Leicester Frith Hospital IAN ANDERSON Groby Road School of Psychiatry and Behavioural Sciences Leicester LE3 9QF ManchesterRoya!Infirmary OxfordRoad ManchesterM139WL

Combination treatment of depression SIR: The question of how to treat depressed patients Dysfunctional attitudes and Beck's cognitive theory who have failed to respond to a first antidepressant of depression agent is of great clinical importance. Seth et a! SIR: I would like to comment on Brittlebank et al's (Journal,October1992,161,562—565)describethe article (Journa!, January 1993, 162, 118—121)onauto successful treatment of such patients by the addition biographical memory in depression. They compared of a selective serotonin reuptake inhibitor (SSRI) a measure of autobiographical memory to the Dys to the tricyclic antidepressant; a potentially more functional Attitudes Scale (DAS; Weissman, 1979) straightforward manoeuvre than lithium augmen with respect to: (a) whether scores on each measure tation or changing to a monoamine oxidase inhibi fell as depression scores decreased (i.e., whether the tor. Points by subsequent correspondents are well variables behaved as state or trait markers); and (b) made (Cowen & Power, Journal, February, 1993, whether scores on each measure predicted depression 162, 266—267)but, given the potential hazards of at three- and seven-month follow-up. The findings combining drugs, may fail to address one critical concerning autobiographical memory are interesting

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