Antidepressants: which one?

There are now 15 effective antidepressant medicines marketed in Canada (eight tricyclic antidepressants, three monoamine oxidase inhibitors, and four medicines with novel chemical structures). The tricyclics remain the drug of first choice for major depressions, because of their proven efficacy over three decades, their known side effect profiles, and the cheaper cost of imipramine and amitriptyline compared to other tricyclics and the new antidepressants. The monoamine oxidase inhibitors are an excellent alternative, and are far safer than earlier reports suggested. Maprotiline offers few advantages over the tricyclics and costs significantly more. Trazodone may be a second- or third-line drug with the advantage of minimal anticholinergic properties. Adequate clinical evaluation of nomifensine has not yet occurred. Neuroleptic and cardiotoxic properties of amoxapine suggest other medicines should be tried first.