Patient education: Tricyclic antidepressants (The Basics)

What are tricyclic antidepressants? — 

Tricyclic antidepressants ("TCAs") are medicines used for treating or preventing pain from long-term conditions such as fibromyalgia, migraine headache, and nerve pain. Nerve pain is often described as burning, shooting, or shock-like pain. It can happen with certain health problems such as cancer or diabetes.

TCAs are also used to treat depression and anxiety.

Common TCAs include nortriptyline (brand name: Pamelor), amitriptyline (brand name: Elavil), and desipramine (brand name: Norpramin).

How will TCAs make me feel better? — 

If you are taking a TCA for pain, it will calm the way your nerves sense pain. You should start to feel some pain relief after a week or more. The dose used to treat pain is lower than the dose used to treat depression.

If you are taking a TCA for depression, after taking it for 2 to 6 weeks, it should:

●Improve your mood

●Make it easier to do everyday tasks

●Help you worry less

●Help with anxiety

How much medicine will I take? — 

Your doctor will prescribe the lowest dose needed to improve your symptoms. Using a low dose at first helps you adjust to the medicine and helps prevent side effects. If the low dose does not work well enough, it can be slowly increased.

TCAs are usually taken once a day. Most people take it right before bed, since it can make you sleepy.

Can TCAs cause side effects? — 

Yes. Common side effects from TCAs are usually mild and go away after a few weeks (table 1). These include:

●Dry mouth

●Constipation

●Dizziness

●Drowsiness

●Weight gain

●Problems with sex

If side effects are hard to manage, do not go away, or worry you, tell your doctor or nurse. They might have ideas for how to lessen or manage your side effects. They can also help you switch your medicine safely if it isn't the right one for you.

Rarely, TCAs can cause serious side effects. Call your doctor or nurse right away if any of these happen:

●Constipation for more than 2 days

●Trouble urinating

●Vomiting

●Changes in vision

●Feeling very lightheaded when you first stand up

Call for emergency help (in the US and Canada, call 9-1-1) if any of these happen:

●Seizure

●Chest pain

●Fast or irregular heartbeat

●Passing out

●Trouble breathing

●Severe allergic reaction

●Took too many pills

When will I start to feel better? — 

Most antidepressants start to work within 2 weeks. But it usually takes at least 4 to 6 weeks before you feel the full effect. In some cases, it might take as long as 12 weeks.

If you don't feel any better after 2 to 4 weeks, ask your doctor or nurse what you can do. They might suggest 1 or more of these:

●Waiting to see if things change

●Taking a higher dose

●Trying a different medicine

●Adding another treatment, such as counseling or cognitive behavioral therapy ("CBT")

Who should not take TCAs? — 

TCAs are not used in people with heart problems or seizures (epilepsy), because they can make these problems worse. Your doctor might do tests to check your heart health before prescribing a TCA. Older people might not be able to take TCAs because side effects can be worse.

TCAs are not usually used in people who are at risk for suicide. This is because they are very dangerous if a person takes too much, or "overdoses." If you are having thoughts of hurting or killing yourself, tell your doctor or nurse immediately. Help is also available in the US and Canada from the 988 Suicide & Crisis Lifeline:

●To speak to someone, call or text 988.

●To talk to someone online, go to chat.988lifeline.org.

How long will I take the medicine for? — 

If you are taking a TCA for pain, you will take it until the painful condition improves. Your doctor or nurse can tell you more.

If you are taking a TCA for depression, you will probably take it for at least 6 to 9 months. If you have severe depression or depression that lasted a long time, it usually makes sense to keep taking your antidepressant for a year or longer. Also, if you have had more than 1 episode of depression, you should probably take the antidepressant for at least a year.

People with depression who recover and then stop taking their medicines often get depressed again. The risk of this increases if you have had several episodes of depression.

It is important not to stop taking your medicine without talking to your doctor. Stopping an antidepressant suddenly can cause symptoms such as headache, nausea, trouble sleeping, or dizziness. Your doctor will usually give you instructions on lowering the dose slowly to prevent these side effects.

How do I stay safe? — 

Take your medicines exactly as your doctor tells you to, so you get the correct amount of each. It might help to use reminders or a weekly pill box (picture 1).

If you have side effects like sleepiness or dizziness, do not drive or operate dangerous equipment. Alcohol can also make these side effects worse.

Antidepressants can cause serious problems if taken with certain other medicines. Your doctors and pharmacists need to know all the medicines you take to help avoid this. This includes any over-the-counter medicines, vitamins, and herbs such as St John's wort. Bring a list of the names and doses of all your medicines each time you visit any doctor. You can find an example of this kind of list at this website: www.fda.gov/media/73856/download.

For more detailed information about your medicines, ask your doctor or nurse for the patient drug information handout from UpToDate. It explains how to use each medicine, describes its possible side effects, and lists other medicines or foods that can affect how it works.

What if I want to get pregnant? — 

Depression can sometimes get worse during pregnancy and after birth. Antidepressants might be used to treat severe depression during pregnancy. Talk with your doctor to understand the risks and benefits for your and your baby's health.

More on this topic

Patient education: Commonly used medicines for depression (The Basics)
Patient education: Depression in adults (The Basics)
Patient education: When you have depression and another health problem (The Basics)
Patient education: Depression during and after pregnancy (The Basics)
Patient education: Side effects from medicines (The Basics)
Patient education: Brand versus generic medicines (The Basics)

Patient education: Depression treatment options for adults (Beyond the Basics)
Patient education: Depression in adults (Beyond the Basics)