My main objection would be that people don't want to have to fill a script 52 times a year. And that side effects are a big reason of why people stop taking a medication to begin with.
I still though don't see how this TCA is the gold standard for depression.
I'll read them if they're more recent. That one is from 1998, which itself makes the claim dubious...
I don't think the system is perfect by any means, but for what it is I think it's great. Never going to be perfect.
We have all these doctors and institutions that prefer SSRIs over TCAs, so I'm just going to trust them on that one. Basically.
I didn't hide the fact that in overdose tricyclics are more toxic thus a valid reason for the introduction of other agents did not exist
BUT only a minority of patients represent a suicide risk so the fact that it might be a bit more fiddly for a minority of patients isn't a sound basis for dismissing the entire class. Neither did I assert that other antidepressants were of no value or inactive. Only that the tricyclics remain
statistically the most effective. If another class works for people, fine. I am never said they didn't, nor that they should stop taking a medication that works.
Find out what the most effective antidepressants are for adults, from this review of more than 500 anti-depressant trials.
evidence.nihr.ac.uk
The
most effective antidepressant compared to placebo was the tricyclic antidepressant amitriptyline, which increased the chances of treatment response more than two-fold (odds ratio [OR] 2.13, 95% credible interval [CrI] 1.89 to 2.41). The least effective was the serotonin and noradrenaline reuptake inhibitor reboxetine, which increased treatment response by 37% (OR 1.37, 95% CrI 1.16 to 1.63).
Clomipramine is still the
‘gold standard’ SNRI drug and may be more effective than other antidepressants in severe depression. Its HCR affinities indicate that it is the most potent and effective single SNRI drug available. Amitriptyline has strong evidence for efficacy, but possibly not greater than that for nortriptyline, which may therefore be preferred in many situations (probably including use in migraine and pain syndromes) because of its advantageous pharmacological characteristics. A direct comparison of nortriptyline vs clomipramine, which has strong evidence for clinically relevant superiority via serotonergic effects, would be useful
This systematic review suggests that
amitriptyline should remain in its position as the gold-standard antidepressant.
Just as the placebo effect is well studied, so is the nocebo effect. If one believes a medicine won't work, there is a measuable reduction in how effective that medicine will be. In the case of antidepressants, the fact that one class doesn't work isn't a good indicator of how effective another class will be.
I've always thought that with mood disorders, almost nobody neatly fits into a single diagnostic criteria. If a person tells their GP that they feel anxious, depressed and can't sleep, is it appropriate to treat all three symptoms seperately or to conclude that the most prominent symptom is likely to be the cause of the other symptoms? Go back sixty years and it was quite likely that a doctor would provide a medication to treat each symptom. But experience has shown that while that approach can be very effective in the short-term, the long-term outcomes were not so good.
I think I'm right in saying that the most effective treatment for unipolar depression is person-centred therapy. Unfortunately person-centred therapy is also the most expensive treatment because it essentially means an open ended series of therapy sessions. It is the patient who decides when they no longer need the treatment. But it involves no chemicals, is tailored to the needs of the patient and usually it's possible to return to the same therapist if more sessions are needed at some later date.
