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Traditional Antidepressants (TCAs)

Traditional antidepressants may also be referred to as “tricyclic” antidepressants (TCAs).

Amitriptyline (Elavil®) Desipramine (Norpramin®) Doxepin (Sinequan®) Imipramine (Tofranil®) Nortriptyline (Aventyl®) Trimipramine

What is this medication used for?

Most traditional antidepressants (TCAs) are not approved by Health Canada for use in children and adolescents.

However, TCAs may help treat anxiety disorders such as post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD) and social anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), insomnia, depression, and pain conditions like migraines, neuralgia and fibromyalgia.

When potential benefits outweigh risks, TCAs may be prescribed “off-label.” Learn more about off-label use:

Tell your doctor or pharmacist if you:

  • Have allergies or bad reactions to a medication
  • Take (or plan to take) other prescription or non-prescription medications, including natural medicines. Some medications interact with TCAs. Your doctor may adjust medication doses or monitor for side effects
  • Have a history (or family history) of heart, kidney, liver or thyroid disease, seizures, arrhythmias, sleep apnea, glaucoma or bipolar disorder
  • Miss a menstrual period, are pregnant, breast-feeding or planning a pregnancy
  • Use alcohol or street drugs. Taking TCAs together with certain substances may cause a bad reaction. Learn more at:

When will the medication start to work?

You (or your family members) may notice improvements in sleep, appetite and energy within the first 2 weeks. However, it may take up to 4 weeks before you begin to feel better. Full beneficial effects may take 6-12 weeks.

TCAs take time to work. Continue taking this medication as prescribed, even if you are feeling better or there are no improvements in the first few weeks.

Talk with your doctor before you increase, decrease or stop taking this medication, even if you feel that this medication has not been helpful or if side effects are bothersome. Your doctor may recommend switching you to a different medication.

This medication is not addictive. Do not stop taking it before talking to your doctor.

How do I take this medication?

TCAs are usually taken once nightly, with or without food, at the same time each night. However, TCAs may occasionally be taken twice daily. TCAs used for insomnia should be taken 30 minutes before bedtime. Usually, you will start with a low dose and slowly increase this dose over several days to weeks, based on how you tolerate it.

Most TCAs are available as tablets, while doxepin and nortriptyline are available as capsules.

Possible common or serious side effects:

Side effects may be more common when starting a medication or after a dose increase. Talk to your doctor, nurse or pharmacist if any side effect concerns you.

  • Dizziness, drowsiness or headache
  • Agitation, anxious thoughts or abnormal dreams
  • Blurred vision or dry mouth
  • Nausea, stomach ache or constipation
  • Increased appetite or weight gain
  • Upper respiratory tract infection
  • In adolescents/adults: changes in sexual performance or interest

Contact your doctor immediately if you experience:

  • Thoughts of hurting yourself, hostility or suicide
  • Changes in mood to an unusual state of excitement, irritability or happiness
  • Muscle twitches, stiffness
  • Uncomfortable sense of inner restlessness or agitation
  • Unexpected rash, seizure, fever or excessive sweating
  • Unusual bruising or bleeding

What precautions should my doctor and I be aware of when taking this medication?

  • While taking TCAs, if you feel dizzy, drowsy or slowed down, do not drive a car or operate heavy machinery. Alcohol could make this worse. Try to avoid alcohol while taking TCAs.
  • TCAs and medications like it are associated with a rare side effect called “serotonin syndrome,” especially when used in combination with other serotonergic drugs such as MAO inhibitors and most other antidepressants. Symptoms include diarrhea, sweating, increased heart rate, tremors, severe muscle stiffness and increased agitation.
  • Do not to stop taking TCAs suddenly. Stopping abruptly is associated with “antidepressant discontinuation syndrome.” This involves flu-like symptoms, trouble sleeping, nausea, irritability, headache and abnormal sensations that feel like electric shocks, burning, tingling or numbness. If stopping or changing medications, your dose should be reduced slowly over several weeks.

What special instructions should I follow while using this medication?

  • Keep all appointments with your doctor and the lab.
  • Your doctor may want to talk to you within 1-2 weeks of starting a TCA, and meet with you over time to make sure it is working well for you and check for side effects.
  • Do not allow anyone else to use your medication. 

What should I do if I forget to take a dose of this medication?

If you take a TCA only at night and forget to take a dose, skip the missed dose and continue regularly with your next scheduled dose.

If you take a TCA more than once a day and forget to take a dose, take the missed dose as soon as you remember and take any remaining doses for that day at evenly spaced intervals. However, if it is close to your next schedule dose, skip the missed dose and continue with your regular schedule. DO NOT double your next dose to try to ‘catch up’.

How do I store this medication?

Keep TCAs in the original container, stored at room temperature away from moisture and heat and protected from light. Keep TCAs out of reach and sight of children.

How does this medication work?

While there are some differences between individual TCAs, all of them act in a similar way. TCAs increase levels of the brain chemicals serotonin and norepinephrine. These brain chemicals do not function properly in people who have depression or anxiety. TCAs improves symptoms of ADHD by increasing norepinephrine in areas of the brain that control impulsive actions, attention and body movement. TCAs improve symptoms of insomnia by decreasing the actions of other brain chemicals (like histamine and acetylcholine). The exact way TCAs improve symptoms of pain disorders is not known.

How well does the medication work in children and adolescents?

Several TCAs have been studied in children and adolescents for treatment of various conditions. Generally, TCAs have shown to be no better than placebo (an inactive pill) for treatment of depression and anxiety disorders in children and adolescents. However, TCAs may be used in children and adolescents for PTSD, migraine prevention, insomnia, ADHD and other conditions when other treatments have not been effective.

Clomipramine is a TCA that is Health Canada approved for treatment of OCD in children and adolescents ages 10 and older. Learn more about clomipramine at:

How long should I take the medication for?

This depends on the symptoms you have, how frequently they occur and how long you have had them. Most people need to take TCAs for at least 6 months. This allows time for symptoms to stabilize and function to improve. After this time, you and your doctor can discuss the benefits and risks of continuing treatment.

Do not increase, decrease or stop taking TCAs without discussing it with your doctor, even if you are feeling better. If you stop taking TCAs suddenly, it is possible that your symptoms may return or you may have a bad reaction.

TIP: Use the Kelty Mental Health Antidepressant Monitoring Form for Children and Adolescents to help measure your progress on this medication.

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