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Precautions for Tricyclic Antidepressants (TCAs)

Abstract: Precautions for tricyclic anti- depressants: Do not start with full dose immediately. The effect may not show until after 4-8 weeks. They should not be taken together with certain heart medications like digoxin and certain medications used to treat seizures such as phenytoin.

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Precautions for Tricyclic Antidepressants (TCAs)

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Written by: Petros Skapinakis, MD, MPH, PhD, lecturer of Psychiatry in the University of Ioannina Medical School, Greece. Eva Gerasi, postgraduate student in the Department of Psychiatry, University Hospital of Ioannina, Greece.
First version: 22 Jul 2008.
Latest revision: 29 Jul 2008.

What must I know and think about when I take/prescribe tricyclic antidepressants (TCAs)?


These medications need to be started at low doses, and the dose should be increased gradually in order to reduce the severity of side effects. Regular blood tests are needed to check the amount of the medication in your blood. Too much of this type of medication in the bloodstream can be dangerous.

Tricyclic antidepressants (like all antidepressants) should not be stopped suddenly. Patients may suffer from withdrawal side-effects afterwards.

These medications may take 4 to 8 weeks to start working.They may take longer to become effective in older adults. Desipramine, nortriptyline, and trazodone have the fewest side effects and may be given to older adults for this reason. However, these medications may not be the preferred choice for treatment of depression in older adults due to the severity of the side effects.
Hospitalization may be needed until they start working especially if the patient is feeling suicidal, as it is possible to overdose in these medications.

TCAs should not be used with:

  • Certain heart medications like digoxin.
  • Certain medications used to treat seizures such as phenytoin.

Names of tricyclic antidepressants:

Amitriptyline, Elavil, Doxepin, Sinequan/Adapin, Nortriptyline, Aventyl/Pamelor, Imipramine, Tofranil, Clomipramine, Anafranil,Desipramine, Norpramin.

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