A result of the extensive use of SSRIs is highlighted in the article by Mamdani and colleagues. Using an Ontario database on drug utilization, they found that since the introduction of SSRIs into Canada, the utilization and costs of antidepressants for the elderly have increased dramatically. Exploring prescriptions of antidepressants from 1993 to 1997, they noted an increase in the prevalence of antidepressant use by the elderly from 9.3% to 11.5%, with SSRIs growing from 9.6% of antidepressant prescriptions to 45.1% over that period. The increase in total expense was due largely to a switch from almost entirely generic tricyclic antidepressants to the SSRIs. This increase occurred despite the fact that generic fluoxetine became available in Canada in 1995. While the increased use of SSRIs and the resultant higher costs may be of concern to health care economists, such costs must be weighed against such potential benefits as 1) better efficacy and restoration of function, because the agents are often better tolerated (a point questioned by Mamdani and colleagues in their article) and patients are understandably more compliant with their treatment (see preceding discussion), and 2) the potential savings in emergency room visits and stays in the intensive care unit associated with overdoses. Further large-scale studies on the cost-benefit ratio would aid in assessing the value of switching from tricyclic antidepressants to SSRIs. (As Mamdani et al. argue, such studies should be performed with nortriptyline, a secondary tricyclic antidepressant with fewer side effects than a tertiary agent, such as amitriptyline.) Still, the increased prescriptions of SSRIs suggest that there is at least a reasonable level of satisfaction with this class of agents in the elderly, and although this study did not focus on fluoxetine, the data are in keeping with the findings from a large-scale study of geriatric depression (7), in which fluoxetine was significantly more effective than placebo.