A tricylic antidepressant. Our preferred tricylic is nortriptyline because of its lower incidence of postural hypotension and relatively moderate anticholinergic effects. There are a variety of other options to consider here, as well. Nefazodone could also be considered. However, there is still little established regarding its efficacy for severe, melancholic depression.
Experts still seem somewhat unconvinced about the efficacy of nefazodone in severe depressions.
Bupropion may not be the best choice if dementia is present since there is a clinical impression that it occasionally induces confusional states. Cardiovascular effects of bupropion in depressed patients with heart disease. American Journal of Psychiatry. Yes Show this place in the flowchart. An augmentation is considered more likely to be helpful.