Tricyclic and tetracyclic antidepressants for depression

Examples

Tricyclic antidepressants (TCAs)

Generic Name	Brand Name
amitriptyline
desipramine	Norpramin
doxepin	Sinequan
imipramine	Tofranil
nortriptyline	Aventyl, Pamelor,
protriptyline	Vivactil
trimipramine maleate	Surmontil

Heterocyclic antidepressants

Generic Name	Brand Name
amoxapine	Asendin
maprotiline

These are older (first-generation) antidepressants. They generally have more side effects than newer (second-generation) antidepressants such as serotonin reuptake inhibitors (SSRIs) and other second-generation antidepressants such as bupropion (Wellbutrin, Wellbutrin SR) and duloxetine (Cymbalta).

How It Works

Symptoms of depression result when certain brain chemicals (neurotransmitters) get out of balance. These medicines balance the brain chemicals, which may help the symptoms of depression.

Why It Is Used

These medicines are used to help the symptoms of major depression. They may be used when other types of antidepressants do not work.

When these medicines are not used

• Some of these medicines are not given to older adults because they can cause severe side effects.
• They usually are not given to people who have low blood pressure or certain heart problems, such as irregular heartbeats.

How Well It Works

Like other antidepressants, cyclic antidepressants relieve depression in most people who have depression.

Side Effects

Side effects may vary among these medicines. Most side effects improve as the person continues to take the medicine.

These medicines may have more common and more serious side effects than newer types of antidepressant medicines such as selective serotonin reuptake inhibitors (SSRIs).

Side effects include:

• Stomach upset and other digestive problems, such as constipation.
• Dry mouth, blurred vision, and/or drowsiness.
• Lowered blood pressure.
• Weight gain.
• Tremors and sweating.
• Inability to urinate (urinary retention).
• Sexual problems.
• Confusion or delirium, in older adults.
• Fatigue.
• Not being able to empty the bladder, or having a hard time urinating.

Desipramine and nortriptyline have the fewest side effects but the side effects can be severe.

FDA Advisory. The U.S. Food and Drug Administration (FDA) has issued an advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when the doses are changed.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Antidepressant medicines work in different ways. No antidepressant works better than another, but different ones work better or worse for different people. The side effects of antidepressant medicines are different and may lead you to chose one instead of another. Tell your doctor about side effects.

You may have to try different medicines or take more than one to help your symptoms. Most people find a medicine that works within a few tries. Other people take longer to find the right one and may need to take the antidepressant and another type of medicine.

Take your antidepressant as your doctor says. Don't quit taking your medicines without talking to your doctor. If you quit suddenly, it can cause dizziness, anxiety, fatigue, and headache. If you and your doctor decide you can quit using medicine, gradually reduce the dose over several weeks.

Start these medicines at low doses. Gradually increase the dose to reduce how bad side effects are.

Regular blood tests may be needed to check the amount of the medicine in your blood. Too much can be dangerous.

Do not suddenly stop taking these medicines. If you decide to stop taking your antidepressant, you will need to lower your dose slowly, with your doctor's help.

You may start to feel better within 1 to 3 weeks of taking antidepressant medicine. But it can take as many as 6 to 8 weeks to see more improvement. If you have questions or concerns about your medicines or if you do not notice any improvement by 3 weeks, talk to your doctor.

It is possible to take too much of these medicines (overdose). People sometimes start taking them while in the hospital, especially if they are suicidal, so doctors can watch for possible overdose.

Tricyclic antidepressants (TCAs) and heterocyclic medicines usually are not used with some heart medicines, such as digoxin (Lanoxin), and some seizure medicines, such as phenytoin (Dilantin). Make sure your doctor has a complete list of all the medicines you are taking.

Taking medicines for depression during pregnancy may make birth defects more likely. If you are pregnant or thinking of becoming pregnant, talk to your doctor. Medicines may need to be continued if your depression is severe. Your doctor can help weigh the risks of treatment against the risk of harm to your pregnancy.

These medicines must be used very carefully in those with bipolar disorder because they may trigger a manic episode. If you have bipolar disorder, your doctor may prescribe them, along with a mood stabilizer.

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Author:	Jeannette Curtis Paul Lehnert	Last Updated: March 13, 2009
Medical Review:	Adam Husney, MD - Family Medicine Catherine D. Serio, PhD - Behavioral Health Lisa S. Weinstock, MD - Psychiatry Peter Hauser, MD - Psychiatry
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