Sunday, May 26, 2019

Tricyclic Antidepressants

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Tricyclic antidepressants were the most commonly prescribed antidepressants until selective serotonin reuptake inhibitors (SSRIs) came along. Doctors still prescribe tricyclic antidepressants, particularly to people who have not been helped by SSRIs. Tricyclics are very effective, and may be more effective than SSRIs for certain individuals and some types of severe depression.

Doses

Tricyclic antidepressants are generally taken once per day. Because they can be sedating, they usually are taken in the evening or at bedtime, when they may promote a better night’s sleep.  

Doses vary widely. It is sometimes helpful to have your blood levels checked to make sure the dose is in the right range. In any case, your doctor will adjust your dose gradually depending on whether you are improving and what side effects you may experience. In order to be effective, you have to take the dose that is right specifically for you. Sometimes a person is not feeling better because the dose is not yet high enough. However, because tricyclic antidepressants can be dangerous if given in too high a dose, it is also important not to take too much. Work carefully with your doctor to adjust the dose to balance the benefits and the risks.    

Generic Name Brand Name Dose* Imipramine Tofranil An average of 150-300 milligrams per day Amitriptyline Elavil, Endep An average of 150-300 milligrams per day Clomipramine Anafranil An average of 75-250 milligrams per day Doxepin Sinequan, Adapin An average of 150-300 milligrams per day Desipramine Norpramin An average of 150-300 milligrams per day Nortriptyline Pamelor An average of 50-150 milligrams per day Protriptyline Vivactil An average of 20-60 milligrams per day Trimipramine Surmontil An average of 75-200 milligrams per day

*These ranges are averages for otherwise healthy adults.   As we age, we metabolize tricyclic antidepressants more slowly. Older people are also more susceptible to side effects. Doses, therefore, may need to be lower in this group.

Side Effects  

When taken in normal, therapeutic doses, tricyclic antidepressants are safe. Common side effects include the following:

  • Dry mouth
  • Blurred vision when reading
  • Constipation
  • A slower urine stream
  • Light-headedness when rising to stand (Called orthostatic hypotension, this refers to a drop in blood pressure that accompanies a posture change.)
  • Sedation, restlessness or poor sleep
  • Sweating
  • Skin rash or other allergic reaction
  • Weight gain
  • Nausea, vomiting or poor appetite
  • Tremor
  • Confusion (especially in the elderly)
  • Increased risk of seizure for people predisposed to seizures
  • Rapid heartbeat

Warnings  

Because tricyclic antidepressants can cause dangerous heart rhythms when the dose is too high, an overdose can be fatal. Anyone who overdoses should be rushed to an emergency room. Because of this overdose risk, doctors and patients may shy away from using tricyclic antidepressants. In fact,  other types of antidepressants (such as selective serotonin reuptake inhibitors) tend to be tried first. Although these risks exist, sometimes, tricyclic antidepressants are the most effective medicine to treat depression, even in someone who thinks about suicide. Therefore, tricyclics can be used to treat depression, particularly if other treatments have failed. Work closely with your doctor to understand the benefits and risks of this treatment.  

Suicide Risk. All antidepressants (not just tricyclic antidepressants) carry warnings about suicide risk.

In October 2004, the Food and Drug Administration began requiring that manufacturers include a warning on package inserts for all antidepressants. The warning mentions the risk of suicidal thoughts, hostility and agitation in both children and adults.  

After you start taking any antidepressant, there is a risk that you may feel worse rather than better. The danger is greatest in the first few weeks of treatment, so make sure you follow-up with your doctor. There is also a small risk for an increase in suicidal thinking and behavior. Fortunately, some research shows that the overall suicide rate decreases in people taking antidepressants. However, a small number of people using antidepressants encounter a lower mood, and feel more anxious, irritable, self-destructive or impulsive.  

Since tricyclic overdoses are so dangerous, other types of antidepressants (such as SSRIs) have been tried. For a significant number of people, however, the positive effects of these medications can outweigh the risks.  

Discontinuation of tricyclic antidepressants. Abruptly stopping your use of these drugs can cause the following:

  • Loss of appetite, nausea, vomiting, diarrhea
  • Runny nose, sweating, muscle aches, fever
  • Tingling, restlessness, insomnia, increased dreaming, dizziness, lightheadedness, anxiety, agitation

The tricyclic antidepressant clomipramine (Anafranil) has a strong effect on serotonin. When you stop using clomipramine, you may experience symptoms similar to those that occur when people stop using selective serotonin reuptake inhibitors. Examples include dizziness, trouble with coordination, headache, nausea, lethargy, tingling, electric-shock-like sensations, vivid dreams, irritability and lowered mood. Symptoms usually peak within the first week and then fade away.

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Jonathan
Medically trained in the UK. Writes on the subjects of injuries, healthcare and medicine. Contact me [email protected]

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