The number of previous treatments with antidepressants was negatively correlated with treatment outcome .
After a first SSRI , any switch within or between classes of antidepressants appears legitimate ( second SSRI , novel dual-acting antidepressants , selective norepinephrine or nor-adrenergic/dopaminergic agents , or tricyclic anti-depressant or mianserin ) .
No unequivocal evidence is available to prove an advantage of a between-class switch .
OBJECTIVE Selective serotonin reuptake inhibitors ( SSRIs ) are frequently used as a first antidepressant for major depressive disorder but have response rates of 50 % to 60 % in daily practice .
For patients with insufficient response to SSRIs , switching is often applied .
This article aims to systematic ally review the evidence for switching pharmacotherapy after a first SSRI .
Nortriptyline in Geriatric Depression Resistant to Serotonin Reuptake Inhibitors: Case Series
Research on treatment-resistant depression in the elderly has been limited , and recommendations for clinical man agement have often been extrapolated from studies using nongeriatric patients . This report describes a series of 10 elderly patients with refractory depression who were treated with nortriptyline  after failing to respond to an ade quate trial of a serotonin reuptake inhibitor .  Seven ( 70 % ) of the patients responded to the addition or substitution of nortriptyline . All seven of the responders have remained on nortriptyline for maintenance therapy , none of whom have experienced recurrence of their depression after an average treatment duration of 1 year . Response to nor triptyline  occurred in about 4 weeks in most patients . The mean daily dose of nortriptyline  was 54 mg , and the mean plasma level was 97 ng/mL. Minor side effects occurred in three patients . No patients developed significant electrocardiogram changes .  Nortriptyline , possibly due to its different mechanism of action , may be effective as either an adjunctive or replacement antidepressant in some cases of geriatric depression that are resistant to sero tonin reuptake inhibitors . ( J Geriatr Psychiatry Neurol 2001 ; 14:28 - 32 )
The number of previous treatments with antidepressants was negatively correlated with treatment outcome .
After a first SSRI , any switch within or between classes of antidepressants appears legitimate ( second SSRI , novel dual-acting antidepressants , selective norepinephrine or nor-adrenergic/dopaminergic agents , or tricyclic anti-depressant or mianserin ) .
No unequivocal evidence is available to prove an advantage of a between-class switch .
OBJECTIVE Selective serotonin reuptake inhibitors ( SSRIs ) are frequently used as a first antidepressant for major depressive disorder but have response rates of 50 % to 60 % in daily practice .
For patients with insufficient response to SSRIs , switching is often applied .
This article aims to systematic ally review the evidence for switching pharmacotherapy after a first SSRI .