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

Table 2 Clinical guideline recommendations on TCA selection in pharmacotherapy of unipolar MDD

Institute, year	Position of TCAs^§	Preference between NOR, CLO, IMI and AMI^†
NICE, 2020 [12]	First-line: SSRI. First switch to another modern antidepressant prior to venlafaxine, TCA or monoamine oxidase inhibitor.	No preference.
DGPPN, 2015 [13]	First-line options include SSRIs, SNRIs and TCAs. Comorbid diabetes mellitus: no sedative TCA. Comorbid pain syndrome: TCA.	NOR: least adverse effects. Avoid CLO in combination with monoamine oxidase inhibitors.
APA, 2010 [14]	First-line: SSRI SNRI, mirtazapine or bupropion. Second-line treatment options include TCAs.	NOR: elderly patients, Parkinson’s disease, smoking cessation.
CANMAT, 2016 [15]	First-line: SSRI, SNRI, mirtazapine, bupropion, agomelatine, mianserin, milnacipran, vortioxetine. Second-line options include TCAs.	CLO: MDD with anxious distress.
WHO, 2012 [16]	First-line options include SSRIs, SNRIs and TCAs. Elderly patients: SSRI. During pregnancy: TCA or fluoxetine.	No preference.
WFSBP, 2013 [17]	First-line: SSRI, bupropion or mirtazapine in mild depression and SSRI, SNRI or TCA in severe depression.	NOR: least adverse effects, e.g., in elderly patients. CLO: comorbid OCD^¶.
Dutch Multidisciplinary Guideline, 2013, 2008 [10, 18]	First-line: SSRI, SNRI, mirtazapine or bupropion. Hospitalized patients: TCA. Elderly patients: SSRI. Psychotic depression: TCA.	NOR: elderly patients. CLO: comorbid anxiety disorder, OCD.

^§ Position of TCAs relative to other first- or second-line options in the pharmacological treatment of unipolar major depressive disorder (MDD)
^† NOR = nortriptyline, CLO = clomipramine, IMI = imipramine, AMI = amitriptyline
^¶ Obsessive-compulsive disorder

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