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Tricyclic Antidepressant Medications

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Tricyclic antidepressants are used to treat depression, anxiety, headaches, chronic pain, and irritable bowel syndrome. They've been around for fifty years. They're not addicting at all. Side effects sometimes limit their use, but they are among the most helpful medications available.

The generic names of these antidepressants are in boldface. Brand names follow in parentheses: Doxepin (Sinequan); Amitriptyline (Elavil); Nortriptyline (Pamelor); Imipramine (Tofranil); Desipramine (Norpramin)

1. What are antidepressants?

They are a family of medications developed to treat depression. They have also been found to be effective in a number of other disorders not related to depression. They are among the safest medications available.

What else are they used for besides depression?

Tricyclic antidepressants are the treatment of choice for:

While reading this article, if you are taking these medications for an indication besides depression, just substitute your particular problem for talk about "depression," since the medication otherwise works the same way.

2. Are they tranquilizers, pep pills, sleeping pills, pain killers, sedatives, hormones, or nerve pills?

No, none of these. They are a unique family of medications completely different from Valium, sedatives, narcotics, etc. They work by restoring normal balance to chemicals in the brain.

3. Are they addicting?

Absolutely not. A person could not become addicted if he wanted to, even if he takes these medications for months or years.

4. Aren't these like "pep pills" or "uppers"?

Absolutely not. Pep pills give anybody a sudden boost or energy, whether they are depressed or not. They are dangerous, and I rarely use them. Antidepressant pills, on the other hand, will do nothing to a person without depression, but will greatly help a person who has a depression. They are among the safest pills in medicine -- safer than, for example, Tylenol or penicillin. They won't damage your kidneys, liver, heart, or nervous system.

5. Do they have undesirable side effects?

Unfortunately, they have pesky side effects. They almost never have serious side effects. They will cause dry mouth. You may become constipated. Some may cause drowsiness, but this is usually temporary. You may sweat more than usual. Some people develop a minor tremor (shaking) of the hands. There are other minor side effects that affect some people, but they are not serious. Tricyclics can make certain illnesses worse: narrow-angle glaucoma, prostatic hypertrophy, and preexisting cardiac arrhythmias.

A few patients stop taking tricyclic antidepressants because the side effects are too annoying: dry mouth, constipation, sweating, or grogginess. Usually you can get through the start-up period when these symptoms are the worst by starting at a low dose, waiting until side effects go away, and then gradually increasing the dose step by step.

Occasionally a side effect limits your ability to take this medication at all. The most common problem is developing "the munchies": a craving to eat sweets that can lead to gaining weight. This rarely occurs with desipramine, but it can occur with amitriptyline or doxepin.

6. Are there interactions with other drugs?

Tricyclic antidepressants usually don't interact with other medications, but there are exceptions you should know about:

7. How do I use this medication?

This medication must be taken regularly, not just when you feel like you need it. In other words, never stop taking the medication because you feel better and think you don't need it. Stop it only when I tell you to.

(The biggest problem with this medicine is that people stop taking it as soon as they feel better. Then their symptoms come back.)

The way you know this medication is working is every time you take a pill, you say to yourself, "I feel GREAT! Why do I have to take this junk?" You can't tell it's doing anything.

8. How long will I have to take this medication?

Usually 3-6 months, but often a year or two. Fortunately, the medications can by taken safely as long as they are needed, even for a lifetime.

9. What else should I know about these antidepressants?
  1. It usually works best to take your medication all in one dose. Usually you should take that dose 2-3 hours before you intend to go to bed. In this way, most of the side effects will occur while you are asleep so that you will not be bothered by them.

    But if the medicine wakes you up, take it early in the day. Desipramine tends to wake people up, although rarely someone will find it sedating. When you start desipramine, begin by taking it in the morning and see how you do.

    Also, these medications may cause you to feel a little nervous at the beginning of the treatment. This is temporary. (If you have manic-depressive disorder, any antidepressant may cause severe agitation. If this occurs, stop the medication and call.)
  2. Amitriptyline, Imipramine, and Doxepin usually cause drowsiness during the first week of treatment. This drowsiness is temporary and goes away within a few weeks. Don't stop taking the drug because of minor drowsiness. If the drowsiness is unbearable, lower the dose and call.

    If a medication makes you persistently sleepy after several days of treatment, cut the dose, or take it every other day. In a week or two, once you get used to it, you should be able to increase the amount you take back to the original dose prescribed.
  3. Tricyclics make most people's mouths feel dry. This is because the saliva glands secrete less saliva whIle you are taking this drug. This side effect is pesky but not serious. Most people get around it by either chewing gum or taking frequent sips of milk or water. Unfortunately, you may have a dry mouth as long as you take the medication. Usually the benefits are worth it unless the dryness is severe.
  4. Most of the good effects of this medication will not appear for one to two weeks. Amitriptyline, Imipramine, and Doxepin will help you sleep right away, but other beneficial effects may be delayed for two to three weeks. When the medication does begin to work, many things will become much better -- energy will increase, sex drive will return to normal, headaches will go away, and the tendency to cry and feel irritable will go away; in other words, you will feel like you are back to normal.
  5. When you do begin to feel back to normal, do not stop the medication. If you do, you will feel worse again in a few days or a week or two.
  6. You cannot get "hooked" on these medications. They are not dope. It makes no difference how much or how long you take these medications. Habituation is simply not possible.
  7. Once you've been taking this medication for a month or more, do not stop it suddenly. (You may get side effects that are the reverse of the initial start-up effects.) Instead, taper the medication slowly over a month and then stop it.
  8. People vary a great deal in how much medication they require -- the effective dose ranges from 10 to 300 mg. per day. Many people with mild depression do well on 25-100 mg. per day, and most with more severe symptoms will require 75-150 mg. per day or more. Figuring out how much you need is usually fairly simple. Start with a small dose and gradually increase it until you have the beneficial effect you desire, or you run into those pesky side-effects. We'll work together to determine the best dose for you.

    Occasionally, someone who has done well on a lower dose for a few months may begin to feel depressed again. Often, that person will feel better with a small increase in dose.
  9. It is extremely important that I see you again after about the first two weeks of treatment in order to evaluate whether our diagnosis and treatment are correct. Do not stop taking the medications until you do see me, unless side-effects are intolerable on the lowest doses.
  10. If anything troublesome happens which you think may be due to the medication, call and let me know what is happening. Many times the problem will have nothing to do with the medication at all. However, it is true that, with a few people, there may be such reactions as tremors, blurring of vision, delay of urination, or perspiration. Such "side reactions" are usually temporary or can be controlled with other medications.
  11. You should be able to work, drive and carry out your usual activities while taking the medication. When first beginning the antidepressant, use caution about driving or engaging in other possibly dangerous activity until you see how the medicine will affect you. This especially applies to Amitriptyline and Doxepin. After the first two or three days, usually you can do anything you wish. If you are too sleepy after that, call me and I will change it to another antidepressant that will not make you so drowsy.
  12. One of the reasons these medications are safe is you cannot hide from troublesome life situations with them. If for example, you do not have the true medical illness of depression, but instead are only working too hard, you will receive no "energy" from these pills. If you have no true depression, but instead are simply unhappy with a life situation that would make anybody unhappy, then the pills will give no happiness.

Last updated Fri, Jun 19, 2015

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©2011, James Gagné, MD