Reasons for choosing a TCA before an SSRI
- Patients with previous episodes of severe depression (especially if it was unresponsive, or only partially responsive, to an SSRI)
- 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’).
- Those with pre-existing history of, or present symptoms of, marked insomnia
- Those with history or present symptoms of gastrointestinal disturbance, GI bleed, reflux, dyspepsia
- 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.
- Those with high anxiety or agitation (may be especially at risk re 5 above).
- Those with conspicuous anorexia and weight loss.
- If concern over cytochrome P450 enzyme drug interactions is relevant. TCAs cause less problems in this area than many SSRIs.
- A history of hyponatremia.
The above factors, and others, suggest a TCA may be the optimal first choice.