Antidepressant selection is a bit of an art.  There are so many considerations that go into choosing which antidepressant should be utilized.  Here’s a few things that I think about where making a recommendation.

• Pain.  The TCA”s and SNRI’s do have some benefit in different pain syndromes like neuropathy and fibromyalgia.  If a patient has depression and needs some help on the pain side of things, these classes go to the top of the list.
• Suicide risk.  It isn’t a fun thing to think about, but in the event that we are worried about a suicidal patient, we need to avoid giving them a way to do that.  The TCA’s are much riskier than the SSRI’s in the situation of drug overdose.
• Adverse effect profile.  SSRI’s can have some subtle differences.  An example here is that sertraline tends to cause more diarrhea than other SSRI’s.  The TCA’s are well known to have not so nice anticholinergic side effects (especially in our elderly population).  Many antidepressants also can cause sexual dysfunction.  Mirtazepine and bupropion are two that will likely not have this adverse effect.  There are certainly more side effects to all of these agents, but I think you get the point.
• Cost.  There are some newer agents out there for depression, but obviously we have a nice sized selection that are now generic.

What else do you think about when recommending an antidepressant?

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