Anecdotally, Give Me a Tricyclic...

I am asked: "I was curious why you called imipramine the gold standard. It doesn't seem to be prescribed as frequently as SSRIs. I also thought MAO Inhibitors were more effective. I'd be interested in more on your view of this. "

Well, all you're gonna get today is one shrink's anecdotal views. And as I tell my patients, "Ask ten shrinks and you'll get ten answers." (Although with DSM, I think it's supposed to be 6 or 7 out of 10 agreeing on diagnosis, at least.)

I'm no researcher, so maybe I used the "gold standard" term wrong. But when drug companies were first trying to demonstrate the efficacy of SSRIs, they compared them to imipramine. That's what I intended to convey.

Imipramine (and the other tricyclic antidepressants) work. And the more experience we gain with SSRI's, the less impressed I am with any edge an SSRI might have in side-effect profile (with the one exception of lethality in overdose).

But, you can never underestimate the power of a good marketing campaign -- and I reckon there is much less money to be made in marketing generic imipramine.

I haven't used MAOI's in years. But anecdotally I found no advantage to them back when I did.

Actually, in adults I almost always try Wellbutrin first: fewer side effects, and still first-line on the best practice guidelines.

Hey, I said it was totally anecdotal today...