“Melancholic depressed patients who are 40 years or older, especially men, appear to show a superior response to the tricyclic antidepressant drug (TCA) nortriptyline, whereas younger patients, especially women, show a superior response to the serotonin reuptake inhibitor (SSRI) fluoxetine.

SSRIs and TCAs appear to be equally effective in adults with major depression, however, some studies suggest that TCAs may be superior to SSRIs in depressed patients with melancholic features.”

I am among a subset of psychiatrists who have suspected that the SSRIs are less robust for the most severe forms of depression and that we have lost something from our therapeutic armamentarium in the last decade’s almost total shelving of the tricyclics. In meeting the pharmaceutical companies’ goal of broadening the market for antidepressants, we have lost depth of efficacy in the most serious cases. The study’s finding of the superiority of SSRIs in younger patients, especially women, is a reflection of the fact that depression in the latter demographic is more often the smouldering, chronic atypical kind associated with personality disorders than the acute melancholic episode of devastating severity.