Reasons for choosing a TCA before an SSRI

1. Patients with previous episodes of severe depression (especially if it was unresponsive, or only partially responsive, to an SSRI)
2. Those whose current episode is severe or shows psychomotor retardation or lack of energy (optimal choices, amitriptyline and clomipramine, my preference is for clomipramine because it is an ‘SNRI’).
3. Those with pre-existing history of, or present symptoms of, marked insomnia
4. Those with history or present symptoms of gastrointestinal disturbance, GI bleed, reflux, dyspepsia
5. Those with history of significant suicidal features. Such patients may be made worse by SSRIs and there is some concern that in a small number a feeling of restlessness (induced by SSRIs) may increase suicidal risk. There is minimal risk of over-dose with the prescribed TCA, because, as part ‘good clinical management’, patients will be attending frequently. A small supply may be issued at each visit if no responsible person is available to supervise the supply. Remember — 95% of those who die by suicide use means other than the prescribed drugs.
6. Those with high anxiety or agitation (may be especially at risk re 5 above).
7. Those with conspicuous anorexia and weight loss.
8. If concern over cytochrome P450 enzyme drug interactions is relevant. TCAs cause less problems in this area than many SSRIs.
9. A history of hyponatremia.

The above factors, and others, suggest a TCA may be the optimal first choice.