When should tricyclic antidepressants be considered for a patient?

Tricyclic antidepressants (TCAs) are typically considered for patients who have not responded adequately to first-line treatments, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). This is due in part to their side effects, which can be more significant than those of SSRIs and SNRIs, making them less desirable as initial treatment options.

Patients may require multiple trials of different SSRIs or SNRIs to determine which medication works best for their specific situation. TCAs might then be introduced only if these first-line medications fail to provide relief from depressive symptoms. The use of TCAs is also guided by the specific nature of the depression being treated, and while they can be effective, their wider range of potential side effects can make prescribers cautious about their initial use.

For mild anxiety, TCAs are generally not the best choice, as other safer and more effective treatments are usually available. The immediate initiation of TCAs upon diagnosis of depression is not typically practiced due to the aforementioned reasons concerning their side effects and the availability of safer alternatives. Thus, the consideration of TCAs is well-aligned with clinical practice guidelines when first-line treatments are ineffective.