Hi, I'm Dr. Tracey Marks, a psychiatrist
and I make mental health education videos.
If you have or have had depression or anxiety
and took medication,
chances are, your doctor prescribed you
one of the newer serotonin antidepressants
like Prozac, Lexapro, or Effexor.
These fall under the category of SSRIs or SNRIs
and that stands for selective serotonin reuptake inhibitor
or serotonin-norepinephrine reuptake inhibitor.
I call these newer, but in this case, new is relative.
The original antidepressants came out around the 1950s
and were called the tricyclic antidepressants.
They get their name from their chemical structure
of having three benzene rings,
whereas the SSRIs are named
by the way that they act in the body
instead of being named by their chemistry.
They are structurally different from the tricyclics
as you can see here with fluoxetine and escitalopram,
compared to imipramine and clomipramine.
Imipramine was the first tricyclic antidepressant
that was manufactured by modifying the drug promethazine,
brand name Phenergan,
which is an antihistamine
used to treat nausea and allergies.
These tricyclic medications were good,
but they had a lot of side effects like sedation,
dizziness, and orthostasis,
which is when your blood pressure and your heart rate
don't respond fast enough to position changes.
So if you stand up too quickly,
you can feel like you're going to pass out
and some people do.
So even though these medications worked,
they weren't that easy to take.
Then along came the SSRIs,
the first of which was fluoxetine, brand name Prozac
that came to the market in 1988.
Several others followed like sertraline, citalopram,
paroxetine, and escitalopram.
These medications also have side effects,
but much less than the tricyclics,
especially when it comes to sedation, orthostasis,
and urinary retention.
With urinary retention,
you have trouble completely emptying your bladder
and feel like you need to keep going back to the bathroom.
So with the improved tolerability
of these newer medications,
the tricyclics fell out of favor.
It's like why bother dealing with all those side effects
if you don't have to?
If you've been treated for depression
or anxiety in the past 20 years,
you may have never been on one.
Well, it turns out, there is a good reason to take them.
Even though over the past 20 years,
the tricyclics have nearly been replaced
by the newer antidepressants,
they're still included in studies
that compare different antidepressants to one another.
And what the research shows
is that certain tricyclic antidepressants
work better for certain conditions.
Here are five of these conditions.
The first one is melancholic depression.
Melancholic depression is a subtype of depression
where you lose all ability to enjoy anything,
have lots of guilt, lose your appetite,
and have early morning awakenings.
You also have prominent slowing of your physical activity.
This is called psychomotor slowing.
You may feel slowed,
but it's often something that other people notice.
It may take you longer to stand up.
You may sit with a slumped posture
and even have droopy eyelids.
You may sigh a lot.
These are some examples of slowed movements.
You may think,
"Well, doesn't everyone with depression
have these symptoms?"
No.
Some people have atypical symptoms,
like being able to shift their mood,
depending on the situation.
I talk about atypical depression in this video.
Also, sometimes depression will make you overeat
instead of causing appetite loss.
So people with melancholic depression tend to respond better
to the tricyclic antidepressants over the SSRIs.
A second condition is depression
in combination with chronic pain.
If you have a pain condition,
like disc disease in your back or fibromyalgia,
you may have been prescribed amitriptyline
or imipramine by a pain specialist.
Usually though, the dose for pain
is lower than what we would use for depression.
Duloxetine, brand named Cymbalta
is also preferentially used
for depression with chronic pain.
Duloxetine is an SNRI.
If you're on duloxetine
and it doesn't seem to be working well enough for you,
you should talk with your doctor about trying a tricyclic
as it's equal or considered to be equal to Cymbalta
and better than the SSRIs.
The third condition is depression
with irritable bowel syndrome.
Because you have more serotonin receptors
in your gut than in your brain,
any of the serotonin-enhancing antidepressants
can cause gut problems
like nausea, diarrhea, or constipation.
So if you already have irritable bowel syndrome,
it can be pretty tricky finding an antidepressant
that doesn't aggravate your condition.
However, two tricyclics in particular,
amitriptyline and imipramine have both been shown
to be more effective for depression than the SSRIs
and are worth giving a try.
The fourth condition is obsessive compulsive disorder.
OCD is not always very responsive to antidepressants alone,
especially if you have more severe symptoms.
Clomipramine has very good evidence
for being more effective in treating OCD.
The fifth situation
is in preventing a relapse of your symptoms
after receiving electroconvulsive therapy.
ECT is probably the most effective treatment for depression.
Some will argue that ketamine is better,
but there's still a lot we don't know
about how long you'll stay without symptoms
after getting ketamine.
Usually once you complete a course of ECT,
which is several treatments,
you have the option of staying off medication
and using ECT for maintenance
or using antidepressants to keep you in remission.
The combination of nortriptyline and lithium
is considered to be the gold standard first-choice treatment
for maintenance after ECT.
Even though you can't prescribe medication for yourself,
the significance of this information
is that if you're not doing as well as you'd like
on your current medication
and you've tried others and still no luck,
you can talk to your doctor about revisiting the tricyclics.
If your doctor trained in the 2000s,
he or she may not have much experience using them
and therefore may not think of them as options
since we have so many other options.
In fact, in my own practice, they are not my first choice
because of the side effects
and I've only talked to a small number of patients
about switching their medication to a tricyclic.
But these medications are still alive and well,
mostly used in lower doses for other conditions.
Examples of other conditions are nerve pain,
migraine headaches, and sleep.
There's a landmark depression study from 2008
called the STAR*D trial.
I'll spare you the details of it,
but it's a very influential study
that looked at what treatments really worked.
The study showed that only about 67% of people
experience full remission from their depression symptoms
with various medication treatments.
67% is the majority, but it's still not a lot.
So suboptimal improvement is real
and it's not that uncommon.
If that seems to be the case for you,
a trial of a tricyclic isn't a reasonable option
for you and your doctor to consider.
Here are the options.
The first generation of tricyclics
are amitriptyline, clomipramine, doxepin, and imipramine.
They have the most side effects when it comes to sedation,
urinary retention, orthostasis,
and potential changes in your heart rhythm.
Because of the cardiac effects,
these medications are not recommended
for someone who has suicidal thoughts
because they can be lethal in overdose.
So what some doctors will do if they want to use it anyway
is to give you a week or two at a time.
The orthostatic issues may make these medications
not a good idea for someone who already has balance problems
or is a fall risk.
They should also be avoided if you have bipolar disorder
as they can bring on a manic episode.
The second generation came afterwards
as a new and improved option.
These are desipramine, nortriptyline, and protriptyline.
These have less of the previously mentioned side effects,
but they still have more than the SSRIs and the SNRIs.
Watch this video for more on atypical depression,
which is a different subtype from the melancholic
and this video talks about treatment-resistant depression.
Thanks for watching.
See you next time.