Bloodwork Monitoring for Adults on Antidepressants

Recommendations by Antidepressant Class

The American College of Neuropsychopharmacology recommends therapeutic drug monitoring (TDM) for Tricyclic Antidepressants (TCAs) due to their narrow therapeutic window and risk of potentially lethal toxicity 1, 2
Plasma level monitoring helps avoid intoxications and optimize dosing to achieve therapeutic levels for TCAs 1
The American Psychiatric Association suggests that while a clear plasma level-clinical effectiveness relationship has not been established for Monoamine Oxidase Inhibitors (MAOIs), TDM may still be useful in situations of noncompliance, nonresponse, adverse effects, or suspected intoxication 1
The National Institute of Mental Health recommends that routine TDM is not generally required for Selective Serotonin Reuptake Inhibitors (SSRIs) but can be cost-effective as it helps determine minimum effective doses 1, 2

The American Geriatrics Society recommends monitoring for older adults (>65 years) due to age-related changes in pharmacokinetics 1
The Centers for Disease Control and Prevention notes that the risk of upper gastrointestinal bleeding rises significantly with age (from 4.1 hospitalizations per 1000 adults aged 65-70 years to 12.3 per 1000 octogenarians) when SSRIs are used in older adults 3
The American Academy of Child and Adolescent Psychiatry recommends TDM for all psychotropic medications in children and adolescents due to developmental differences in pharmacokinetics 1, 2

The American Heart Association recommends monitoring cardiovascular function, particularly arrhythmias and blood pressure fluctuations, in elderly patients on TCAs 1
The American Gastroenterological Association suggests monitoring for gastrointestinal bleeding risk is important, especially in older adults or those on concomitant NSAIDs when using SSRIs 3
The Endocrine Society recommends monitoring for hyponatremia, particularly within the first month of treatment in older adults when using SSRIs 3
The American Psychiatric Association recommends considering monitoring for suicidality, particularly in the first month of treatment when risk is highest for all antidepressants 3

The National Institute of Mental Health warns that relying solely on blood levels without clinical correlation can lead to inappropriate treatment decisions; therapeutic windows should be interpreted in the context of the clinical situation 1
The American College of Clinical Pharmacology notes that combining pharmacogenetic testing with TDM may be beneficial in certain cases to consider pharmacogenetic factors that affect drug metabolism 1, 2
The American Geriatrics Society recommends overlooking the need for monitoring in special populations (elderly, children, pregnant women) where pharmacokinetics may differ significantly from the general adult population 1