Tricyclic Antidepressants

Tricyclic antidepressants are used to treat depression and some other conditions. They often take 2-4 weeks to work fully. A normal course of antidepressants lasts at least six months after symptoms have eased. Side-effects may occur, but are often minor and may ease off. At the end of a course of treatment, you should gradually reduce the dose before stopping completely.

Tricyclic antidepressants are not just for depression

Tricyclic antidepressants are used to treat depression. They are also used to treat some other conditions such as migraine, panic disorder, obsessive-compulsive disorder, recurrent headaches, and some forms of pain. The word tricyclic refers to the chemical structure of the medicine.

How do antidepressants work?

Antidepressants alter the balance of some of the chemicals in the brain (neurotransmitters). These are thought to play some part in causing depression and other conditions.

How effective are tricyclic antidepressants?

About 5-7 in 10 people with moderate or severe depression have an improvement in symptoms within a few weeks of starting treatment with an antidepressant. However, up to 3 in 10 people improve with dummy tablets (placebo) as some people would have improved in this time naturally. So, if you have depression, you are roughly twice as likely to improve with an antidepressant compared with taking no treatment. But, they do not work in everybody. As a rule, the more severe the depression, the greater the chance that an antidepressant will work well.

Note: antidepressants do not necessarily make sad people happy. The word 'depressed' is often used when people really mean sad, fed-up, or unhappy. True depression is different to unhappiness and has persistent symptoms (which often include persistent sadness). See separate leaflet called 'Depression' for more information about this condition.

The success rate of tricyclic antidepressants can vary when used to treat the other conditions listed above (migraine, etc).

How quickly do tricyclic antidepressants work?

Some people notice an improvement within a few days of starting treatment. However, an antidepressant often takes 2-4 weeks to build up its effect and work fully. Some people stop treatment after a week or so thinking it is not helping. It is best to wait for 3-4 weeks before deciding if an antidepressant is helping or not. If poor sleep is a symptom of the depression, it is often helped first, within a week or so.

With some types of tricyclic antidepressant, the initial dose that is started is often small and is increased gradually to a full dose. (One problem that sometimes occurs is that some people remain on the initial dose which is often too low to work fully.)

If you find that the treatment is helpful after 3-4 weeks, it is usual to continue. A normal course of antidepressants lasts at least six months after symptoms have eased. If you stop the medicine too soon, your symptoms may rapidly return. Some people with recurrent depression are advised to take longer courses of treatment.

When you are taking tricyclic antidepressants

It is important to take the medication each day at the dose prescribed. Do not stop taking them abruptly. This is because you may develop some withdrawal symptoms. The dose is usually gradually reduced before stopping completely at the end of a course of treatment. But don't do this yourself - your doctor will advise on dosage reduction when the time comes. It is best not to stop treatment or change the dose without consulting a doctor.

Are there different types of tricyclic antidepressants?

There are several different types. They include: imipramine, amitriptyline, doxepin, mianserin, trazodone, and lofepramine. Each of these comes in different brand names.

There is no best type that suits everyone. A doctor makes a judgement as to which one would best suit. Things such as your age, other medicines that you may take, other medical problems, possible side-effects, and previous use of antidepressants are taken into account. If the one chosen does not suit, it is sometimes necessary to change the dose, or change the preparation. Also, if tricyclic antidepressants do not help then another type of antidepressant may be advised.

What about side-effects and risks?

Most people have either minor, or no, side-effects. Possible side-effects vary between different preparations. The leaflet that comes in the medicine packet gives a full list of possible side-effects. You should read this before you start taking the medicine. It is beyond the scope of this leaflet to list all side-effects, but the following highlights some of the more common or serious ones. As a rule, tell your doctor if a side-effect persists or is troublesome. Your doctor can advise on the best course of action - for example, to stop the medication, a switch to a different drug, etc.

The most common side-effects

These include: a dry mouth, constipation, sweating, slight hesitancy in passing urine, slight blurring of vision. It is worth keeping on with treatment if these side-effects are mild at first. Minor side-effects may wear off after a week or so. Frequent drinks of water will help a dry mouth. Also, some people find that sucking pineapple chunks helps with the flow of saliva and helps to ease the feeling of dry mouth.

A possible sedating effect

Tricyclic antidepressants can cause a sedating effect (drowsiness) in some people. You must be aware of this possibility, especially if you are a driver as it may impair your ability to drive safely. Any sedative effect is likely to be greatest in the first month of starting treatment, or on increasing the dose. The Driver and Vehicle Licensing Agency (DVLA) advises that you should not drive during this time if you feel that you are drowsy or sedated at all. Also, do not operate machinery if you feel drowsy.

Small increased risk of fractures

Research studies suggest that there is a small increased risk of fractures in people taking tricyclic antidepressants. However, the reason for this increased risk is not clear.

Antidepressants and suicidal behaviour

In recent years there have been some case reports which claim a link between taking antidepressants and feeling suicidal, particularly in teenagers and young adults. This may be more of a risk in the first few weeks of starting medication or after a dose increase. It is debatable whether this possible risk is due to the medicine or to the depression. If it is due to the medication then the risk remains very small. And, overall, the most effective way to prevent suicidal thoughts and acts is to treat depression. However, because of this possible link, see your doctor promptly if you become increasingly restless, anxious or agitated, or if you have any suicidal thoughts. In particular, if these develop in the early stages of treatment or following an increase in dose.

Sexual problems

Problems with sexual function are a common symptom of depression. However, in addition to this, all antidepressants may cause some problems with sexual function. For example, decreased libido (sex drive), difficulty getting an erection, delayed orgasm, and impaired ejaculation have been reported as side-effects in some people taking tricyclic antidepressants.

Are antidepressants addictive?

Tricyclic antidepressants are not tranquillisers, and are not thought to be addictive. Most people can stop tricyclic antidepressants without any problem. At the end of a course of treatment it is usual to reduce the dose gradually over about four weeks before finally stopping. This is because some people develop withdrawal symptoms if an antidepressant is stopped abruptly. If you have withdrawal symptoms it does not mean that you are addicted to the the medicine, as other features of addiction such as cravings for the medicine do not occur.

Withdrawal symptoms that may occur include: dizziness, anxiety and agitation, sleep disturbance, flu-like symptoms, diarrhoea, abdominal cramps, pins and needles, mood swings, feeling sick, and low mood. These symptoms are unlikely to occur if you reduce the dose gradually. If withdrawal symptoms do occur, they will usually last less than two weeks. An option if they do occur is to restart the drug and reduce the dose even more slowly.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at the following web address: www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines may have caused. If you wish to report a side-effect, you will need to provide basic information about:

  • The side-effect.
  • The name of the medicine which you think caused it.
  • Information about the person who had the side-effect.
  • Your contact details as the reporter of the side-effect.

It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.