Tricyclic Antidepressants: Risks, Benefits, and Alternatives

Q: What is a tricyclic antidepressant?

A tricyclic antidepressant (TCA) is a class of antidepressant medications used to treat various mood disorders, such as depression, anxiety, and certain chronic pain conditions. TCAs work by increasing the levels of neurotransmitters like serotonin and norepinephrine in the brain, which can help improve mood. They are an older class of antidepressants and are generally considered less preferred due to their potential for more side effects.

Tricyclic antidepression drugs, such as amitriptyline, desipramine, and doxepin, may harm your heart, according to a new study conducted by researchers at University College London (UCL). This tricyclic antidepressant safety concern may extend beyond individuals who are being treated for depression, as these older antidepressants are also used to treat anxiety, sleep problems, headache, and back pain, among other conditions.

Amitriptyline, a tricyclic antidepressant, is sometimes prescribed for managing symptoms of POTS (postural orthostatic tachycardia syndrome), especially for pain and certain neurological effects. Known as amitriptyline POTS treatment, it requires careful monitoring due to its potential side effects. Though amitriptyline POTS usage isn’t its primary purpose, some patients find relief from specific POTS-related symptoms.

Although tricyclic antidepressants are one of the oldest classes of antidepressants, they are still used extensively, according to eMedExpert. Today, selective serotonin reuptake inhibitors (SSRIs) have replaced tricyclic antidepressants for depression treatment, primarily because patients tolerate SSRIs better, and they are considered safer.

Researchers at University College London compared the use of tricyclic antidepressants with SSRIs or no antidepressant use in nearly 15,000 individuals in Scotland. Overall, older antidepressants were linked with a 35 percent increased risk of cardiovascular disease, while the use of SSRIs was not.

Based on these findings, Dr. Mark Hamer, senior research fellow in the Department of Epidemiology and Public Health at UCL, remarked that they “suggest that there is an association between the use of tricyclic antidepressants and an increased risk of cardiovascular disease that is not explained by existing mental illness.” The study results thus indicate that tricyclics have properties that are responsible for the greater risk.

Previous research has shown tricyclic use to be associated with a significantly higher rate of severe cardiovascular side effects, such as increased heart rate, as well as arrhythmias, blood pressure abnormalities, and congestive heart failure. They have also been linked with weight gain and diabetes, which are risk factors for cardiovascular disease.

The UCL study’s authors note that other factors may be involved in the possible link between tricyclic antidepressant use and cardiovascular disease. Hamer pointed out that individuals who take antidepressants are more likely to be overweight, smoke, and not get sufficient exercise, as well as risk factors for cardiovascular disease.

Before it can be determined with more certainty whether tricyclic antidepressants are safe, “there needs to be more research looking closely at the effects of these drugs on your heart,” notes Amy Thompson, senior cardiac nurse at the British Heart Foundation. Because antidepressants help a great many people, “it would be unwise for anyone taking them to stop based on the results of this study alone.”

How Do Tricyclic Antidepressants and SSRIs Work?

Antidepressants are a class of drugs that work on the neurotransmitters in the brain to correct their chemical imbalances and thus reduce the symptoms of depressive disorders.

Neurotransmitters are essential communication links between the nerve cells in the brain. They reside within the vesicles found in nerve cells and transmit signals from one nerve cell to another target nerve cell, muscle cell, or gland cell.

When other nerves do not take up the neurotransmitters, they are taken back by the same nerves, and the process is called ‘reuptake. Tricyclic antidepressants work by inhibiting the reuptake of neurotransmitters like serotonin, dopamine, and norepinephrine, allowing their levels to increase in the brain. By targeting these neurotransmitters, tricyclic antidepressants help improve mood regulation. Overall, tricyclic antidepressants are commonly used to manage symptoms of depression effectively.

Antidepressants or anti-depression drugs, in general, target a specific neurotransmitter and inhibit their reuptake, causing their levels to rise up around the nerves within the brain. The selective serotonin reuptake inhibitor or SSRI antidepressant drug , affects the serotonin levels in the brain.

Serotonin is one of the several chemicals involved in the transmission of messages between the brain cells. It is commonly known as the ‘feel-good chemical’ as it causes a relaxed state of well-being.

Generally, serotonin circulates in the brain before being absorbed into the bloodstream. SSRIs help to prevent the absorption of serotonin in the blood, which results in a higher level of serotonin being maintained in the brain. Low levels of serotonin are linked with depression, and conversely, increased levels of the chemical can help relieve depression.

One thing to note here is that SSRIs don’t make the body produce more serotonin. They only help the body to utilise it more effectively without causing major side effects. Hence, SSRIs are probably the best drugs for depression and anxiety treatment. This is why SSRIs are often preferred over and tricyclic antidepressants for OCD treatment. While tricyclic antidepressants for depression and tricyclic antidepressants for OCD treatment are effective, SSRIs generally provide safer options, especially for long-term use.

Some examples of tricyclic antidepressant medications are amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Pamelor), amoxapine, protriptyline (Vivactil), clomipramine (Anafranil), doxepin (Sinequan), imipramine (Tofranil), trimipramine (Surmontil).

Examples of selective serotonin reuptake inhibitors for depression treatment are citalopram (Celexa), fluvoxamine (Luvox), paroxetine (Paxil), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), sertraline (Zoloft).

SSRIs for Depression: What Pregnant Women Need to Know

SSRIs (Selective Serotonin Reuptake Inhibitor) are generally prescribed before tricyclic antidepressants for depression because they have fewer side effects Although there are certain side effects involved with the use of SSRIs, people can hardly cause any damage to themselves by taking an SSRI. However, it is advisable to exercise some caution while taking SSRIs, especially by children and pregnant women.

In pregnant women, SSRIs may increase the chances of heart and lung problems and certain birth defects. But leaving depression untreated can also have a negative impact on pregnancy as well. So, doctors and pregnant women need to compare the risks of taking SSRI treatment to the risks of untreated depression.

To reduce the risks, pregnant women can go for different SSRI to treat their depression. For instance, Paroxetine (Paxil) is associated with heart defects, brain disorders and breathing problems in newborns. So, doctors recommend switching to fluoxetine (Prozac) or citalopram (Celexa) during pregnancy as they are known to produce no serious side effects.

Do we somewhere need to give a disclaimer that these are just suggestions and educational in nature. They have to visit their doctor/ psychiatrist for advice and have to be under supervision. For this and for others too where we have given explanations about specific drugs and their effects on neurotransmitters.

How Tricyclic Antidepressants Are Used Beyond Depression

Tricyclic antidepressants (TCAs) are not only prescribed for depression but are also effective in treating a variety of other conditions. Their ability to influence neurotransmitter levels in the brain makes them versatile for managing several disorders. While their primary use has traditionally been for mood disorders, their benefits extend well beyond depression. Below are some of the key areas where TCAs are commonly used:

Anxiety Disorders: Tricyclic antidepressants, particularly in cases of obsessive-compulsive disorder (OCD), help reduce anxiety and intrusive thoughts.
Chronic Pain: They are often prescribed for managing chronic conditions like neuropathic pain, fibromyalgia, and migraines, where other treatments may be less effective.
Sleep Disorders: Given their sedative effects, TCAs are commonly used to treat insomnia, particularly when it is related to depression or anxiety.
PTSD: Tricyclic antidepressants are sometimes used as part of the treatment plan for post-traumatic stress disorder (PTSD), helping reduce symptoms such as hyperarousal and flashbacks.
POTS-Related Pain: TCAs are occasionally prescribed for managing pain associated with postural orthostatic tachycardia syndrome (POTS), helping patients deal with its neurological symptoms.

Although effective for these conditions, it’s important to note that TCAs must be used with caution. Regular monitoring for potential side effects, including cardiac issues, is essential during treatment.

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FAQs

1. What is a tricyclic antidepressant?

A tricyclic antidepressant (TCA) is a class of medication prescribed for mood disorders like depression and OCD, and is sometimes used to treat chronic pain conditions. Tricyclic antidepressants function by raising serotonin and norepinephrine levels in the brain, which may help enhance mood.

2. Is amitriptyline an SSRI?

Amitriptyline is not an SSRI (Selective Serotonin Reuptake Inhibitor). It is a tricyclic antidepressant.

3. Who should not take tricyclic antidepressants?

Tricyclic antidepressants are generally not recommended for individuals with certain medical conditions or risk factors, including those with a history of heart problems, glaucoma, urinary retention, and those taking monoamine oxidase inhibitors (MAOIs).

4. Which is safer: SSRI or tricyclic antidepressants?

Generally, SSRIs (Selective Serotonin Reuptake Inhibitors) are considered safer than tricyclic antidepressants (TCAs). SSRIs have a lower risk of side effects, reduced potential for overdose, and are better tolerated. TCAs have a higher risk of side effects, particularly cardiac and anticholinergic effects, and can be more dangerous in overdose.

5. What is a risk factor for tricyclic antidepressants?

A risk factor associated with tricyclic antidepressants (TCAs) is their potential to cause bone marrow suppression. This can lead to a reduction in blood cell production, resulting in anaemia, leukopenia (low white blood cell count), and thrombocytopenia (low platelet count). Monitoring blood cell counts is essential during TCA therapy, as this rare side effect can be severe.‍

6. How do tricyclic antidepressants work?

Tricyclic antidepressants (TCAs) work by blocking the reuptake of neurotransmitters like serotonin and norepinephrine in the brain. This increases their levels, which helps improve mood and reduce symptoms of depression. However, TCAs can also affect other neurotransmitters, leading to potential side effects like dry mouth, blurred vision, and constipation.