Concluding panel discussion

Dr. S. Montgomery: This is a fundamental clinical problem, and in my opinion the summary of the clinical findings is that there is not a defined sub-group of patients who should receive mianserin and who would respond to mianserin rather than another drug. In the U.K. we are most concerned about the out-patients who may overdose. For these patients we are much happier to use a safer antidepressant, so by and large our practice in the U.K. has changed over the last five years while mianserin has been with us, so that now general practitioners and psychiatrists are inclined to use mianserin and other of the new generation of antidepressants which seem to be safer. We prescribe the safer antidepressants for those patients who may be thought to be at risk. Now, this has the effect that mianserin is used in cases that are certainly not endogenous depression. It is used in patients with personality disorders with an underlying depression, in patients with a history of alcoholism who are depressed, and who we suspect may overdose without warning. We have tended to change our clinical practice so that mianserin is now used in a wider range of disorders. It is perfectly true as you say, Professor Lingjaerde, that the evidence for efficacy in the reactive group is not as good as it is in the endogenous group, but as clinicians we are inclined to put safety first and to use a safer drug, even in a group for which antidepressant efficacy is not as firmly established.