Fluvoxamine and tricyclic antidepressants (TCAs): how do the TCAs compare as "new" drugs with established fluvoxamine?

The tricyclic antidepressants (TCAs) are still considered as first-line treatment for depression, despite the availability of the selective serotonin reuptake inhibitors (SSRIs). This paper considers the current situation in reverse by assuming that only the SSRIs, in particular fluvoxamine, are available and the TCAs (amitriptyline, imipramine, clomipramine and dothiepin) are the potential "new" drugs. The criteria for an "ideal" antidepressant are discussed and the efficacy, safety and cost-effectiveness of these agents are compared.