Provided antidepressant drugs are prescribed at an adequate dose and taken regularly, 60-70% of patients with moderate or severe depression should respond within 3-4 weeks. Meta-analyses have shown little evidence that any particular drug or class of antidepressant is more efficacious than others, but there are four possible exceptions to this general statement.
• Small trials have suggested that the SNRI agent venlafaxine, in high dose (> 150 mg/day) may have greater efficacy than other antidepressants.
• Amitriptyline appears to be slightly more effective than other TCAs and also SSRIs but this advantage is compromised by its poor tolerability relative to more modern agents.
• The older MAOIs (e.g. phenelzine) may be more effective than other classes in 'atypical' depression, a form of depressive illness where mood reactivity is preserved, lack of energy may be extreme and biological features are the opposite of the normal syndrome i.e. excess sleep and appetite with weight gain.
• Evidence suggests that in patients hospitalised with severe depression, TCAs as a class (also venlafaxine) may be slightly more effective than either SSRIs or MAOIs.
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