Tricyclic antidepressants tertiary amines highly

Tricyclic Antidepressants
Tertiary amines: (highly anticholinergic, more sedating, greater lethality in overdose):
1. Amitriptyline (Elavil): useful in chronic pain, migraines, and insomnia.
2. Imipramine (Tofranil)
a. Useful in panic disorders
3. Clomipramine (Anafranil)
a. Useful in treating OCT
4. Doxepine (Sinequan)
a. Useful in treating chronic pain
b. Emerging use as a sleep aid in low doses
Secondary Amines: Metabolites of tertiary amines (less anticholinergic, less sedating).
1. Nortriptyline (Pamelor, Aventyl)
a. Least likely to cause orthostatic hypotension
b. Useful in treating chronic pain
2. Desipramine (Norpramin)
a. More activating, least sedating
b. Least anticholinergic
Side effects of TCAs
a. Lethal in overdose- must assess suicide risk! Agitation, tremors, ataxia, delirium,
hypoventilation from CNS depression, myoclonus, hyperreflexia, seizures, and coma are
signs of overdoes.
b. TCAs are highly protein bound and lipid soluble, and therefore can interact with other
medications that have a high protein binding.
c. Antimuscarinic effects (also called anticholinergic): dry mouth, constipation, urinary
retention, blurred vision, tachycardia, exacerbation of narrow angle glaucoma.
d. Weight gain.
e. Antiadrenergic properties (cardiovascular side effects).

Monoamine Oxidase Inhibitors (MAOIs)
1. MAOIs are not used a first-line agents because of the ↑ safety and tolerability of newer agents.
However, MAOIs are considered very effective for certain types of refractory depression and in
refractory panic/anxiety disorder:
a. Phenelzine (Nardil)
b. Tranylcypromine (Parnate)
c. Isocarboxazid (Marplan)
Side Effects:
1. Serotonin syndrome occurs when SSRIs and MAOIs are taken together or if other drugs cause ↑
serotonin levels.
a. Initially characterized by lethargy, restlessness, confusion, flushing, diaphoresis, tremor, and
myoclonic jerks.
b. May progress to hyperthermia, hypertonicity, rhabdomyolysis, renal failure, convulsions,
coma and death.
c. Wait at least 2 weeks before switching from SSRI to MAOI, and at least 5-6 weeks with
fluoxetine.
2. Hypertensive crisis: Risk when MAOIs are taken with tyramine-rich foods or sympathomimetics.
a. Foods with tyramine (red wine, cheese, chicken liver, fava beans, cured meat) cause a
buildup of stored catecholamines.
b. In addition to markedly elevated BP, this also characterized by headache, sweating,
nausea and vomiting, photophobia, autonomic instability, chest pain, arrhythmias, and
death.
c. Orthostatic hypotension is most common
d. Drowsiness
e. Weight gain
f. Sexual dysfunction
g. Dry mouth
h. Sleep dysfunction
i. Start low and go slow!
Antidepressants Use in other Disorders
1. OCD: SSRIs (in high doses), TCAs (clomipramine)
2. Panic disorder: SSRIs, TCAs (Imipramine), MAOIs
3. Eating disorders: SSRIs (in high does), TCAs, and MAOIs
4. Dysthymia: SSRIs
5. Social phobias: SSRIs, TCAs, MAOIs
6. GAD: SSRIs, SNRIs (venlafaxine), TCAs
7. PTSD: SSRIs
8. Depressive phase of manic depression: SSRIs
9. Insomnia: Mirtazapine, TCAs (amitriptyline)

Mood Stabilizers
1. Mood stabilizers are used to treat acute mania and to help prevent relapses of manic episodes in