Tricyclic Anti-depressants Medication

Complications /Information to beware of/General tips:

Do not wait, phone for an ambulance if have or develop:

• CNS depression

• Antidepressants are recommended as first-line treatment for moderate and severe depression, depression that has persisted for two years or more (irrespective of severity), or mild depression that has persisted for longer than three months.

Depression in adults: treatment and management . National Institute for Health and Care Excellence . 2022.https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#treatment-for-a-new-episode-of-less-severe-depression

Cleare A, Pariante C, Young A, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015;29:459–525. doi:10.1177/0269881115581093

• Antidepressants have been shown to be equally effective in treating a first episode of depression and up to 60% of patients show a response within the first two weeks of treatment.

Posternak MA, Zimmerman M. Therapeutic effect of follow-up assessments on antidepressant and placebo response rates in antidepressant efficacy trials. Br J Psychiatry. 2007;190:287–92. doi:10.1192/bjp.bp.106.028555

• Antidepressants are also used to treat other conditions, including anxiety disorders, obsessive compulsive disorder and neuropathic pain (peripheral neuropathy).

NHS Medicines and Psychiatry — antidepressant uses. NHS. 2021.https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/antidepressants/uses/

One may try different antidepressants for the following reasons:

• The initial antidepressant is not working (providing the adequate response) for them and this can occur for many reasons (there is no specific one). Factors such as age, sex, quality of life, financial burden, a lack of support network and other comorbid conditions — such as substance misuse, chronic pain and hypothyroidism — can contribute to limited/no response to an antidepressant.

Al-harbi. Treatment-resistant depression: therapeutic trends, challenges, and future directions. PPA. 2012;:369. doi:10.2147/ppa.s29716

• The patient is experiencing side effects i.e weight gain, increased anxiety and insomnia (lack of sleep).
  • Some side effects can be short term or manged via counselling, however some may need judgement from the medical professional of benefit vs the severity of side effect of the medication involved and if severe how much it impacts their function of life.
  • If adverse effects are intolerable, Maudsley Prescribing Guidelines recommend considering switching antidepressants as early as after one to two weeks from commencement.

• All antidepressants show a pattern of response where the rate of improvement is highest during week one to two and lowest during weeks four to six.

Taylor D, Barnes TR, Young AH. The Maudsley Prescribing Guidelines in Psychiatry. Wiley Blackwell 2021. https://dl.uswr.ac.ir/bitstream/Hannan/32636/1/9781119442608.pdf (accessed Jan 2023).

Criteria for defining antidepressant response

Antidepressant response and non-response is assessed through comparison of baseline scores using depression rating scales. There are several formal rating scales that can be used to assess symptom severity to produce scores to assess response, such as the Hamilton Depression Rating Scale and the Patient Health Questionnaire (PHQ-9)

• Non-response is defined as ≤25% decrease in symptom severity compared with baseline;
• A partial response is defined as a 26–49% decrease in symptom severity compared with baseline;
• A response is defined as a ≥50% reduction in symptom severity cores compared with baseline

• Patients showing no improvement will likely not respond to the prescribed drug at that dose; however, if a patient has trialled several antidepressant treatments with minimal effect, it is advisable to consider longer trials of treatment before considering further switching.

Withdrawal symptoms (list not exhaustive)

Typical symptoms include:

• Unsteadiness, vertigo or dizziness;
• Altered sensations (e.g. electric shock sensations sometimes described as ‘brain zaps’);
• Altered feelings (e.g. irritability, anxiety, low mood, tearfulness, panic attacks, irrational fears, confusion or, very rarely, suicidal thoughts);
• Restlessness or agitation;
• Problems sleeping;
• Sweating;
• Abdominal symptoms (e.g. nausea);
• Palpitations, tiredness, headaches, and aches in joints and muscles

Depression in adults: treatment and management. National Institute for Health and Care Excellence. 2022.https://www.nice.org.uk/guidance/ng222

Please beware of:

• Seretonin Syndrome

Please talk to your healthcare professional (i.e Medical Doctor/Pharmacist) for further advice