Of course, I would not prescribe a tricyclic antidepressant if the side effects of these drugs would aggravate an existing medical condition or when the patient has a history of overdose and suicide attempts. If the sedative agent can be shown to be effective at decreasing the target symptoms, its use is less likely to be flagged during an audit. However, you must carefully document the effects of sedative drug therapy. For example, a case can be made if the patient's level of functioning deteriorates each time the drug is discontinued and if it takes longer for them to return to their previous level of functioning. In patients with behavioral disturbances of dementia who are being treated with SSRIs, we often use sedating drugs in the evening.
Many patients do well with lower doses and experience fewer side effects.
However, because SSRIs tend to be tolerated so well compared with tricyclic antidepressants and because clinicians are in the habit with tricyclic antidepressants of starting low and titrating up, many prescribers do not stop at the low end. With increasingly larger doses, the risk of side effects increases, and clinicians may find they need to add a sedative drug to alleviate these adverse effects. Thus, if the sedative drug is being used to control the side effects of the SSRI, I recommend adjusting the SSRI dose. Sedating a patient for any length of time to treat a drug side effect is inappropriate. On the other hand, use of sedation in an attempt to achieve better efficacy or a faster onset of action may be justified.