Tricyclics boost serotonin and noradrenaline and can be used to help the symptoms of:

• Bipolar depression in the short-term
• Depression, their main use
• Eating disorders
• Insomnia in very low dose
• OCD (Obsessive Compulsive Disorder) (only clomipramine)
• Panic disorder
• PTSD (Post-Traumatic Stress Disorder
• Seasonal Affective Disorder
• Social anxiety

The tricyclics were one of the most commonly prescribed antidepressants but the SSRIs have taken over. Tricyclics may also help neuropathic pain.  

There are many other antidepressants. All these drugs seem to be equally effective at the proper dose but have different side effects to each other. If one drug does not suit you, it may be possible to try another.

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The brains has many naturally occurring chemical messengers. Two of these are called serotonin (sometimes called 5-HT) and noradrenaline. Both are important in the areas of the brain that control or regulate mood and thinking. It is known that these two chemical messengers are not as effective or active as normal in the brain when someone is depressed. Tricyclic antidepressants increase the amount of these chemical messengers in the brain. This can help correct the lack of action of these messengers and help to improve mood. The tricyclics can also effect another chemical in the brain called "acetylcholine" and this is the cause of some of their side-effects.

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Tablets and capsules:
Tablets and capsules should be swallowed with at least half a glass of water whilst you are sitting or standing. This is to make sure that they reach the stomach and do not stick in the throat.
Liquids:
Your pharmacist should give you a medicine spoon or oral syringe. Use it carefully to make sure you measure the correct amount. Ask your pharmacist for a medicine spoon if you do not have one. Shake the bottle well before use as the drug can settle to the bottom and cause you to get too low a dose at the start and too high a dose at the end of the bottle. Your mouth may feel a little numb after taking one of these liquids as it can have a local anaesthetic effect. This is common and nothing to worry about.
If it is necessary for you to have an injection it will be given by a nurse or doctor.

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Take your tricyclic as directed on the medicine label. Try to take it at regular times each day. Taking it at mealtimes may make it easier to remember as there is no problem about taking any of these drugs with or after food. If the instructions say to take them once a day this is usually best at bedtime as they may make you drowsy at first. They are not, however, sleeping tablets.

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It may take as long as two weeks or more before the tricyclics start to have any effect on your mood, and a further three or four weeks for this effect to be reaching its maximum. Unfortunately in some people the effect may take even longer to occur e.g. several months, especially if you are older.

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This should be discussed with your doctor, as people respond differently. Some people may need to continue taking them for months or even years. It is usually necessary to take them for at the very least a month after you have got better. However, it is usually best to take them for at least 6 to 12 months to make sure you are fully over your illness. If you have been depressed more than once, it is best to keep taking an antidepressant for several years as this will reduce the chance of you becoming ill again.

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Tricyclics are not "addictive" as such (e.g. no one abuses them), but if you have taken them for eight weeks or more you may get some "discontinuation" effects if you stop them suddenly. These do not mean that the antidepressant is addictive. For a drug to be addictive or produce dependence, then it must have a number of characteristics:

    * should produce craving for the drug when the last dose "wears off"
    * there should be a "reward" (e.g. a good feeling) from taking the drug
    * should produce tolerance ie you need more drug to get the same effect
    * should produce withdrawal symptoms specific to that drug
These characteristics come from the World Health Organisation.
Thus antidepressants, if stopped suddenly, may produce some "discontinuation" symptoms but these are probably more of an "adjustment" reaction from sudden removal of a drug rather than "withdrawal". It would be fair to say that not everyone agrees with this.

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It is unwise to stop taking them suddenly, even if you feel better. Two things could happen. Firstly, your depression can return if treatment is stopped too early (see "How long will I need to keep taking them for?"). Secondly, you might also experience some mild "discontinuation" symptoms (see also above). At worst, these could include headache, restlessness, diarrhoea, nausea, 'flu-like symptoms, lethargy, abdominal cramps, sleep disturbance and mild movement disorders. They can start shortly after stopping or reducing doses, are usually short lived, will go if the antidepressant is started again and can even occur with missed doses.

If you get these discontinuation symptoms, you have a number of options:

    * If they are not severe, you can wait for the symptoms to go - they usually only last for a few days or weeks
    * Ask for something to help your symptoms in the short-term e.g. a sedative or sleeping tablet
    * Start the medication again (the symptoms should go) and then try reducing the dose more slowly over a longer time e.g. reduce the dose by about a quarter (25%) every 4-6 weeks
    * Switch to another antidepressant - this sometimes helps

When the time comes your doctor should withdraw the drug slowly e.g. by reducing the dose gradually every few weeks. You should discuss this with your doctor.

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Start again as soon as you remember unless it is almost time for your next dose, then go on as before. Do not try to catch up by taking two or more doses at once as you may get more side-effects. You should tell your doctor about this next time you meet.

If you have problems remembering your doses (as very many people do) ask you pharmacist, doctor or nurse about this. There are some special packs, boxes and devices which can be used to help you remember

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Use the information in the table below to find out about side effects associated with specific tricyclic antidepressant medication.

Table adapted from UK Psychiatric Pharmacy Group leaflets, with kind permission www.ukppg.org.uk

Do not be worried by this list of side effects. You may get none at all. There are other rare side-effects. If you develop any unusual symptoms ask your doctor about them next time you meet.

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Although a few people can lose weight on tricyclic antidepressants, some gain weight. This is partly due to an increased in appetite and/or a craving for sweet food caused by the drugs. It may also be that the drugs reduce your metabolism, so that you do not metabolise food as quickly. So, not only do you eat more, you use the food less well. It is impossible to know what the effect on your weight may be because each person will be affected differently. Unfortunately all the tricyclic antidepressants seem to have the same effect.

If you do start to put on weight or have problems with your weight, your doctor can arrange for you to see a dietician for advice. Any weight you put on can be controlled while you are still taking this medication, with expert advice about diet. In some people this weight gain can be a serious problem. If it causes you distress make sure your doctor knows about this. A change in drug e.g. to a different type of antidepressants, or change in dose may be necessary in extreme cases. Your doctor can arrange for you to see a dietician.

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Drugs can affect desire (libido), arousal (erection) and orgasmic ability. The tricyclics are know to affect all three stages in some people. Lack of desire and delayed orgasm is known to occur, although the opposite has been reported rarely as well. If this does seem to have happened, you should discuss this with your doctor, as a change in dose, timing or drug may help minimise any problem. Any problem is reversible.

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These drugs may make you feel drowsy. You should not drive (see below) or operate machinery until you know how they affect you. You should be careful as they may affect your reflexes reaction times. They are not, however, sleeping tablets, although if you take them at night they may help you get to sleep.

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You should avoid alcohol except in moderation if you are taking a tricyclic, as it may make you feel more sleepy. If this happens, you will need to take extra care if you need to drive or operate machinery and you must seek advice on this.

^8.10

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You should have no problem with any foods or drinks, other than alcohol (see separate question).

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The tricyclics have many interactions with other medicines:

• Tricylics can cause drowsiness so if taken with benzodiazepines (e.g. diazepam, lorazepam, temazepam), older antihistamines, benzodiazepines (e.g. diazepam, lorazepam, temazepam), melatonin or alcohol, it will cause more drowsiness
• Tricyclics have anticholinergic effects (e.g. dry mouth, blurred vision) so be careful if taken with sedative antipsychotics (e.g. pericyazine, chlorpromazine, olanzapine, quetiapine)
• Tricyclics have cardiac effects (so be careful if used with amiodarone or disopyramide)
• Most tricyclics increase the amount of serotonin in the brain so should not usually be taken with similar drugs, e.g. SSRIs (e.g. citalopram, fluoxetine, paroxetine, sertraline), moclobemide, MAOIs (e.g. phenelzine, isocarboxazid, tranylcypromine), trazodone, St. John's wort, venlafaxine, duloxetine or trazodone.
• The effects of tricyclics can sometimes be increased by some antipsychotics (e.g. haloperidol), aspirin, calcium-channel blockers (e.g. diltiazem, verapamil), fluconazole, cimetidine, some SSRIs (e.g. fluoxetine, paroxetine), terbinafine or methylphenidate
• The effect of tricyclics can be decreased by phenylephrine and some other treatments for colds and ‘flu

This does not necessarily mean that this will happen in everyone or that some of these medicines can not be used together. It just that you may need to follow your doctor's instructions very carefully. There are many other possible drug interactions.

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You should have no problems with "The Pill" and any of the tricyclics.

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It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs.

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine.

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press.

It may be helpful to know that in the USA, the FDA (Food and Drug Administration) classifies medicines in pregnancy in five groups:
# A = Studies show no risk, so harm to the unborn child appears only a remote possibility
B = Animal and human studies indicate a lack of risk but are not fully conclusive
C = Animal studies indicate a risk but there is no safety data in humans
D = a definite risk exists but the benefit may outweigh the risk in some people
X = the risk outweighs any possible benefit

The tricyclics are classified as either "C" or "D" (amitriptyline "D", amoxapine "C", clomipramine "C", doxepin "C", nortriptyline "D" and trimipramine "C"). The others are not available in the USA and so are not classified. One large study showed no evidence of a teratogenic effect and no increase in spontaneous abortions, although another study showed a very slightly increased rate of problems. Animal tests show a low risk of danger but some problems have been reported and so you should seek personal advice from your GP, who may then if necessary seek further specialist advice. There have been some reports of discontinuation effects (e.g. jitteriness) in the newborn child and so it may be possible to reduce your dose a bit before your due date. A recent study has shown no evidence of any short or long-term effects on intelligence and language development, although there was a slight reduction in the length of pregnancy (by about 6 days).

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Not usually. Some people who need to take higher doses occasionally need a blood test to make sure they are getting enough, but not too much, of the tricyclic. (1.7.09)

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The tricyclics can affect your driving in two ways. Firstly, you may feel drowsy and/or get blurred vision at first when taking any of the tricyclics. Secondly, the tricyclics can slow down your reactions or reflexes. This is especially true if you also have a dry mouth, blurred vision, constipation etc. (the so-called "anticholinergic side effects"). Until these wear off, or you know how your tricyclic affects you, do not drive or operate machinery. You should be careful as they may affect your reaction times or reflexes even though you feel well.

Under Section 4 of the Road Traffic Act 1988 anyone driving while unfit to drive, due to illness or any drug, can be prosecuted. Under UK law it does not matter if the drug is a prescribed medicine or an illegal drug. It’s the effect on your driving that is the main thing. If your ability to drive might be reduced due to illness or medicines, under UK law you must let your insurance company know. If you don’t, the insurance might say this is as 'withholding a material fact' (ie not telling them something they ought to know) and might mean that if you have an accident they might not pay up. Your doctor will be able to advise you.

Medical rules for all drivers:
For the full story click here (opens in new window) and go to "Medical standards". Here there is a pdf document (regularly updated) called "At a glance guide to the current medical standards of fitness to drive" that can be downloaded. It is aimed at medical practitioners (GPs).
For the "Customers guide" (ie a guide for the general public) click here (opens in new window) and download the 'Customer service guide for drivers with medical conditions'.

How to tell the UK DVLA:
If you need to tell the DVLA and you already have a license, you need to download the medical questionnaire from the DVLA website. Or you can call the DVLA to ask them to send it to you. You also need to fill out a form to give your consent for doctors from the DVLA doctors to contact your doctor or a specialist. You can either post, fax or email these forms back to:
Drivers Medical Group, DVLA, Swansea, SA99 1TU
Tel: 0870 600 0301
Fax: 0845 850 0095
Email: eftd@dvla.gsi.gov.uk
Web www.direct.gov.uk/motoring (opens in new window)
You should always allow DVLA to contact your doctor, as what your doctor says will help the DVLA decide if you can keep your license. Rarely, the DVLA may ask you to have a (free) medical examination, which will be free. This is called a medical enquiry.

What happens next
If you give the DVLA all the information they need, they can usually sort things out within 15 days. If they need more information from you, your doctor or other sources, they will try to sort it out within 90 days. What they decide will also depend on what you’re doing e.g. driving a bus is different to driving down to the shops. What can happen includes:

• You may be able to keep your license or be issued with a new one.
• If the DVLA’s doctor thinks your fitness to drive needs to be reviewed again, you may be given a license valid for 1, 2 or 3 years.
• Your license may be taken from you (revoked) or your application refused. This will only happen if you do not meet the standards of fitness to drive at the moment. If this happens, you would be told the reasons for the decision. You would also be told when you can apply again.

Driving safely
If you want to carry on driving, you must take sensible steps to reduce any risk:

• Avoid driving when you are tired or ill
• Do not drive after having any alcohol as this can make an drowsiness worse (a third of all fatal road traffic incidents involve alcohol-dependent drivers)
• Avoid driving at night, dusk or in bad weather
• Avoid motorways, dual carriageways and the rush hour
• Give yourself plenty of time. Don’t rush
• Be extra careful if you have not slept well the previous night

As some medicines can affect your driving, be extra careful:

• If starting a new medicine
• After a change in dose (especially an increase)
• If you are on a high dose or seem very sensitive to side effects
• If you are taking any medicines for other symptoms e.g. antihistamines for hay fever or allergies
• If your medicine causes you blurred vision, drowsiness, poor co-ordination, poor attention

If you are driving less than 2000 miles a year, once you consider insurance, tax, MoT, repairs, maintenance and petrol, you may actually find it is cheaper to get taxis and busses, and walk the short journeys.

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