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. 2021 Oct 1;21(1):481.
doi: 10.1186/s12888-021-03490-x.

Tricyclic antidepressants for major depressive disorder: a comprehensive evaluation of current practice in the Netherlands

Cornelis F Vos  1   2 , Rob E Aarnoutse  3 , Marijke J M Op de Coul  4 , Jan Spijker  4   5 , Mascha M Groothedde-Kuyvenhoven  6   7 , Raluca Mihaescu  8 , Sonja J W Wessels-Basten  8 , Jordy J E Rovers  9 , Sophie E Ter Hark  10   11 , Aart H Schene  10   11 , Marlies E J L Hulscher  12 , Joost G E Janzing  10   11
Affiliations

Tricyclic antidepressants for major depressive disorder: a comprehensive evaluation of current practice in the Netherlands

Cornelis F Vos et al. BMC Psychiatry. .

Abstract

Background: Traditionally tricyclic antidepressants (TCAs) have an important place in treatment of major depressive disorder (MDD). Today, often other antidepressant medications are considered as first step in the pharmacological treatment of MDD, mainly because they are associated with less adverse effects, whereby the position of TCAs appears unclear. In this study we aimed to examine the current practice of TCAs in treatment of unipolar MDD.

Methods: A mixed methods approach was applied. First, a selection of leading international and national guidelines was reviewed. Second, actual TCA prescription was examined by analyzing health records of 75 MDD patients treated with the TCAs nortriptyline, clomipramine or imipramine in different centers in the Netherlands. Third, promotors and barriers influencing the choice for TCAs and dosing strategies were explored using semi-structured interviews with 24 Dutch psychiatrists.

Results: Clinical practice guidelines were sometimes indirective and inconsistent with each other. Health records revealed that most patients (71%) attained therapeutic plasma concentrations within two months of TCA use. Patients who achieved therapeutic plasma concentrations reached them on average after 19.6 days (SD 10.9). Both health records and interviews indicated that therapeutic nortriptyline concentrations were attained faster compared to other TCAs. Various factors were identified influencing the choice for TCAs and dosing by psychiatrists.

Conclusions: Guideline recommendations and clinical practice regarding TCA prescription for MDD vary. To increase consistency in clinical practice we recommend development of an up-to-date guideline integrating selection and dosing of TCAs, including the roles of therapeutic drug monitoring and pharmacogenetics. Such a guideline is currently lacking and would contribute to optimal TCA treatment, whereby efficacy and tolerability may be increased.

Keywords: Antidepressant agents; Clinical practice guidelines; Major depressive disorder; Qualitative approach; Tricyclic antidepressants.

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Conflict of interest statement

For this research there are no conflicts of interest to report.

Figures

Fig. 1
Fig. 1
Most important factors influencing TCA selection by psychiatrists
Fig. 2
Fig. 2
Most important factors influencing TCA dose-adjustment by psychiatrists
See this image and copyright information in PMC

References

    1. Bromet E, Andrade LH, Hwang I, Sampson NA, Alonso J, de Girolamo G, et al. Cross-national epidemiology of DSM-IV major depressive episode. BMC Med 2011;9: 90. https://doi.org.10.1186/1741-7015-9-90. - PMC - PubMed
    1. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. Lancet 2018;392: 1789–1858. https://doi.org/10.1016/S0140-6736(18)32279-7. - PMC - PubMed
    1. Chockalingam R, Gott BM, Conway CR. Tricyclic antidepressants and monoamine oxidase inhibitors: are they too old for a new look? Handb Exp Pharmacol, 2019;250: 37–48. https://doi.org/10.1007/164_2018_133. - PubMed
    1. Abbing-Karahagopian V, Huerta C, Souverein PC, Abajo F, de Leufkens HGM, Slattery J, et al. Antidepressant prescribing in five European countries: application of common definitions to assess the prevalence, clinical observations, and methodological implications. Eur J Clin Pharmacol, 2014;70: 849–857. https://doi.org/10.1007/s00228-014-1676-z. - PubMed
    1. Bauer M, Monz BU, Montejo AL, Quail D, Dantchev N, Demyttenaere K, et al. Prescribing patterns of antidepressants in Europe: results from the factors influencing depression endpoints research (FINDER) study. Eur Psychiatry, 2008;23: 66–73. 10.1016/j.eurpsy.2007.11.001. - PubMed

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