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No longer considered a first-line treatment for depression, tricyclic antidepressants are nonetheless effective — and the best choice for some depressed people. What do you need to know about them?

Tricyclic antidepressants were revolutionary in the treatment of depression when they first came on the market in the 1950s, but they've since largely been superseded by new-generation antidepressants such as SSRIs, which have fewer side effects, come with a lower risk of overdose, and patients are less likely to stop using them.

While you're unlikely to be prescribed a tricyclic antidepressant as a first-choice option for depression, TCAs do "work" — that is, they can effectively treat the symptoms of depression, just as well as newer-generation antidepressants. 

Who may be prescribed a tricyclic antidepressant, which medications are we concretely talking about, what are the possible side effects, and what else should you know? Let's take a look!

Who may be prescribed tricyclic antidepressants for depression?

Two categories of depressed people may be prescribed tricyclic antidepressants:

  • People who have tried other antidepressants, like SSRIs and SNRIs, without success — that is, other antidepressants didn't alleviate their symptoms. TCAs are a "second-choice" or even "third-choice" treatment in this case. 
  • Folks who have depression as well as another disorder that can effectively be treated with tricyclic antidepressants — most commonly anxiety disorders or nerve pain, but also obsessive compulsive disorder and even adult bedwetting. (It goes without saying that TCAs can also be prescribed to people who don't suffer from depression but do have another disorder that these medications can treat.)

Which TCA could you be prescribed?

Among the tricyclic antidepressants that your doctor may consider if TCAs are already "on the table" are:

  • Amitriptyline — which one study identified as the most effective antidepressant, not just the most effective TCA, out there. 
  • Desipramine (Norpramin, Pertofrane). 
  • Imipramine (Tofranil). 
  • Maprotiline (Ludiomil), sometimes considered a tetracyclic antidepressant. 
  • Nortriptyline (Pamelor). 
  • Protriptyline (Vivactil)
  • Trimipramine (Surmontil). 
Your prescribing doctor will start you on the lowest possible dose of your new antidepressant, especially if you are switching from either fluoxetine or paroxetine. If that lower dose works well for you, you'll stay on it. In most cases, this will mean a dose of 25 to 50 mg a day, though you may be put on a 10 mg dose if you are going to be taking protriptyline, and if you're prescribed maprotiline, your starting dose is likely to be as high as 75 mg. 

What are the possible side effects of tricyclic antidepressants?

As with many medications, the possible side effects of tricyclic antidepressants can range from "a bit annoying" to "really dangerous", with anything in between also possible. Not every patient will experience the same side effects, so this scary list isn't necessarily a look into your future, but it's good to be aware of the possibilities. 

The side effects of TCAs include:

  • A dry mouth, constipation, confusion, trouble urinating, and changes to your vision, such as blurry vision. (These are the "anticholinergic" side effects.)
  • Arrhythmia and low blood pressure as you change position (orthostatic hypotension).
  • Seizures. 
  • Sexual dysfunction and a lowered libido. 
  • Drowsiness.
  • Profuse sweating. 
  • Weight gain. 

Patients who notice side effects should let their healthcare provider know — never continue to "suffer in silence", thinking your side effects are normal or will go away on their own. Do not stop taking your TCA without a green light from your doctor, either!

Sometimes, it will be necessary to switch to a different medication, but other times, lifestyle changes (like using chewing gum to combat a dry mouth, drinking more water, or changing the time at which you take your antidepressant) or adding another drug to combat side effects will make your tricyclic antidepressant tolerable for you. 

What else should you know?

Tricyclic antidepressants are not suitable for everyone — you shouldn't be on a TCA if you have heart problems, a seizure disorder, liver problems, an enlarged prostate, or glaucoma, for instance. TCAs can also interact with other medications you take and with alcohol. Before you start taking a TCA, make sure that your doctor is aware of your medical history and knows what other medications you use. If you are a woman, let your doctor know if you are pregnant, breastfeeding, or trying to conceive before starting a tricyclic antidepressant. 

Follow dosage and other instructions:

  • Even if the side effects are pretty bad, never just stop taking a tricyclic antidepressant. This isn't just because your depression symptoms could suddenly worsen if you do so, but also because TCAs cause withdrawal symptoms like nausea, sweating, headaches, and symptoms reminiscent of the flu. TCAs need to be tapered off — their dose gradually reduced over a period of time — when you're ready to stop taking them. 
  • Never take more than you're told too — this can be extremely dangerous. 

Finally, always seek emergency medical care if you are feeling suicidal — go to your doctor, head for the emergency room, call an ambulance, anything that can get you the support you need really quickly. Some people who have recently started taking antidepressants suddenly feel suicidal, and this is something you should be aware of. This risk doesn't mean that taking the antidepressants that were prescribed to you is the wrong move, though, as antidepressants offer the best chance of recovering from moderate to severe depression.

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