TCAs

=Tricyclic Antidepressants=

How they work
//TCAs// //inhibit reuptake of noradrenaline and serotonin into presynaptic terminals. Although unrelated to the therapeutic effects of the TCAs, they also block cholinergic, histaminergic, alpha1-adrenergic and serotonergic receptors. Clomipramine has a greater effect on serotonin transport than other TCAs.//

Questions to Ask
What medications? //drugs that may contribute to serotonin toxicity// - medical conditions? //prostatic hypertrophy (increases urinary retention), closed angle glaucoma, epilepsy, bipolar disorder, conditions exacerbated by tachycardia (severe ischaemic heart disease, coronary heart disease etc.)// - allergies?

Treatment with, or within 14 days of stopping, a MAOI Treatment with, or within 2 days of stopping, moclobemide

//Elderly:// Avoid using low dose TCAs for sedation as the risks (including falls) outweigh benefit, and sedative effect decreases with time. (Nortriptyline has lowest hypotension, anticholinergic and sedation effects)

How to take
- All TCAs are equally effective in major depression - Give as a single dose at night to aid compliance; if insomnia develops or daytime anxiolytic effect is desirable, give in 2 or 3 divided doses - Alter dose in increments every 2–3 days as needed - Although adverse effects may appear early, therapeutic response is usually delayed by 2 weeks - Do not stop taking this medicine suddenly unless your doctor tells you to. - Withdraw TCAs slowly to avoid withdrawal symptoms

Side effects
sedation, dry mouth, blurred vision, decreased lacrimation, constipation, weight gain, orthostatic hypotension, sinus tachycardia, urinary hesitancy or retention, reduced GI motility, anticholinergic delirium (particularly in the elderly and in Parkinson's disease), impotence, loss of libido, other sexual adverse effects, tremor, dizziness, sweating, agitation, insomnia, anxiety, confusion
 * Common:**

Blurred vision, drowsiness and dry mouth may lessen or disappear after about 7 days. Take at night to reduce daytime drowsiness - check BP (supine and standing) before and after starting treatment and after each dose change

Other advice?
- increased suicidal thoughts and behaviour can occur soon after starting antidepressants, particularly in young people; monitor patients frequently and carefully early in treatment

CMI
Amitriptyline: Clomipramine: Dothiepin: Doxepin: Imipramine: Nortriptyline: Trimipramine: