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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by newo38 on June 15, 2009, at 2:22:19
I have only taken ssri's and want to switch to a tca because of sexual side-effects. What does it feel like? Like celexa?
Posted by linkadge on June 15, 2009, at 6:59:41
In reply to What are TCa's like?, posted by newo38 on June 15, 2009, at 2:22:19
TCA's do not feel like celexa at all (imho). The only one that might feel remotly like celexa is clomipramine.
The TCA's all have affinity for the serotonin and norepinephrine reuptake systems. Some TCA's are more selective to norepeinephrine (nortriptyline, desipramine) some to serotonin (clomipramine) and some are about equal (imipramine).
In my opinion they generally have a lot more antidepressant umph. They can be better for dealing with apathy and anhedonia than SSRI's.
They may feel a little sedating (or activating) at first, but these side effects diminish somewhat over time.
Chosing a TCA will depend mainly on your baseline symptoms (typical vs. atyipcal depression) and / or level of insomnia and/or anxiety.
Linkadge
Posted by Zana on June 15, 2009, at 15:16:26
In reply to Re: What are TCa's like?, posted by linkadge on June 15, 2009, at 6:59:41
I haven't taken a TCA in a long time but I think they in general have good AD efficacy and that the main reason Pdocs steer away from them are the side effects- anticholenergic eg dry mouth, constipation and weight gain. But I have noticed a lot of experienced people who post suggest them.
Zana
Posted by bleauberry on June 15, 2009, at 18:15:53
In reply to What are TCa's like?, posted by newo38 on June 15, 2009, at 2:22:19
Link said it pretty well.
If we look at metastudies, numbers, statistics, TCAs don't perform any better than the SSRIs you have been on. But if we look at the real world outside of academia and clinical settings, TCAs do anecdotally have more power on depression. Patient experience rapidly over-rules clinical experience.
Why the difference? Clinical studies for the most part have rather rigid exclusion rules to cherrypick a defined patient sample that is NOT representative of the people who walk into doctor's offices everyday. Therefore, any results of clinical analysis are flawed in a realworld setting.
TCAs are called dirty drugs because they are not selective. Celexa for example is considered a clean drug because it is selective for serotonin and nothing else. That is viewed as a benefit. I personally, as well as Dr Gillman at psychotropical.com, view that as a handicap...the dirtier ones work better. We don't want selective. We want drugs that hit multiple targets.
TCAs have different side effects. Common to most of them are dry mouth, constipation, and early sleepiness/fatigue. Those diminish or disappear with time.
Some are more activating, some are more sedating. Amitriptyline for example is often given in low doses for sleep and is probably one of the world's best sleep meds that can be taken longterm. It is also very good for aches and pains, a benefit of its dirtyness. Desipramine is more activating. Somewhere inbetween would be Nortriptyline. The two with the least side effects are Nortriptyline and Desipramine. Of all the TCAs, I would guess Nortriptyline is the most commonly used of them all for depression, though one of the others could work better if it didn't work well.
Clomipramine is still, after almost 50 years, considered the antidepressant for all others to be compared to. The problem with it is that few people can get up to therapeutic doses with its side effects.
The hardest part with any of them is getting through the first couple of months with the side effects...dry mouth, blurry vision, constipation, maybe some brain fog.
Sexual side effects can happen with any of them, but are I believe much less frequent than with the serotonin selective meds.
Here is an idea to seriously consider. What is better than an SSRI, and better than a TCA? Both combined. Some of the best results, and a side effect burden not any greater than either alone, comes from combinations such as Nortriptyline+Zoloft, Nortriptyline+Celexa, Nortriptyline+Prozac, or Desipramine with any of them, or Amitriptyline in modest doses for both sleep and depression along with the SSRI. With this strategy you can likely take only half the dose of Celexa or whatever that you are accustomed to taking.
I mentioned psychotropical.com. You should go there and check it out. Lots of good reading on different types of antidepressants and the experience of a doctor who has treated over 1000 patients with them.
Posted by newo38 on June 15, 2009, at 22:30:57
In reply to Re: What are TCa's like?, posted by bleauberry on June 15, 2009, at 18:15:53
Thanks you Bleauberry, I might take St. John's wort and try to get by on that. I just have this agitation, irritability and obsessiveness that is toguh to deal with.
Posted by HyperFocus on June 17, 2009, at 16:56:43
In reply to Re: What are TCa's like?, posted by bleauberry on June 15, 2009, at 18:15:53
> Here is an idea to seriously consider. What is better than an SSRI, and better than a TCA? Both combined. Some of the best results, and a side effect burden not any greater than either alone, comes from combinations such as Nortriptyline+Zoloft, Nortriptyline+Celexa, Nortriptyline+Prozac, or Desipramine with any of them, or Amitriptyline in modest doses for both sleep and depression along with the SSRI. With this strategy you can likely take only half the dose of Celexa or whatever that you are accustomed to taking.
But beware liver enzyme interactions - taking something like Prozac can inhibit the liver enzymes that metabolize something like amitryptiline, so you can end up with dangerously high toxic levels of the TCA taken in combination with Prozac. Be careful if trying this combo - keep your doctor in the loop.
Posted by Brainbeard on June 21, 2009, at 6:10:58
In reply to Re: What are TCa's like?, posted by newo38 on June 15, 2009, at 22:30:57
I like your story, Bleauberry. I'm a fan of Gillman myself too. I do think though that Gillman is a bit one-sided in his critique of the newer antidepressants. The commercial theatre of the pharmaceutical industry and the striving for drugs that hit a single target are only part of the story. There are valid and rational reasons behind the development of the SSRIs, as Dr. Preskorn so eloquently explains in his online book about these drugs (http://www.preskorn.com/books/ssri_toc.html). Selectivity doesn't just mean hitting only one target, but also avoiding hitting the wrong targets, which, in the end, is what TCA's do. Gillman thinks that the side-effects of the TCA's have been greatly exaggerated for commercial purposes. On the one hand, he's right; on the other hand, the side-effects of the TCA's CAN be disproportionally inconvenient, and their possible lethality IS a major drawback for a certain group of people.
Still, the SSRIs aren't by far as ideal as the pharmaceutical industry would have them to be; their side-effects, especially in the long-term, can actually be quite DEPRESSING.
Plus, the multiple action of the TCA's still makes for a unique combination of therapeutic qualities that can only be approached by augmenting SSRIs with at least one other drug.
It must be said, though, that clomipramine is such a strong SRI that it offers all the side-effects of a tertiary amine TCA *PLUS* the side-effects of a strong SSRI (loss of libido, possibly teeth grinding etc.) Nevertheless, emotional numbing might be prevented with clomipramine by the NRI action of its metabolite.That's another point I would like to mention just for completeness: taking a tertiary amine TCA in practice means taking TWO drugs, namely the teriary amine TCA and its active metabolite.
The most important ones:imipramine (relatively strong, mildly sedative SNRI) -> desipramine (strong NRI). Since desipramine potentially has a half-life of more than hundred hours, and imipramine a half-life of less than 24 hours, the desipramine tends to dominate on higher dosages.
amitriptyline (dirty, sedative, anxiolytic NSRI -> nortriptyline (sedative, anxiolytic NRI)
clomipramine (strong, sedative, anxiolytic SRI and SNRI) -> desmethylclomipramine (NRI). Also with clomipramine, the metabolite has a longer half-life, so on higher dosages the NRI-action is boosted significantly more than the SRI-action. In fact, clomipramine is such a strong SRI that even 10mg is enough to reach the amount of serotonin reuptake inhibition that a typical therapeutic dose of an SSRI delivers (http://archpsyc.ama-assn.org/cgi/content/full/60/4/386).
Combining an SSRI with a TCA is indeed a great idea. I'm thinking of combining the low dose imipramine I'm taking now with sertraline (Zoloft). Combining TCA's by themselves is also a great possibility, although apparently not much explored. I'm thinking of combining my imipramine with low dose amitriptyline.
HyperFocus made a necessary point: fluoxetine (Prozac) elevates TCA-levels enormously; paroxetine (Paxil/Seroxat) elevates them considerably; and sertraline (Zoloft) elevates them considerably as well on higher dosages. Fluvoxamine (Luvox), although not a 2D6-inhibitor, inhibits 1A2 and 3A4 and thereby elevates clomipramine levels enormously. Interestingly, since fluvoxamine inhibits clomipramine's conversion to desmethylclomipramine, it boosts clomipramine's SRI-action while blocking its NRI-action, which can be helpful for some people. I've been on a combination of 150mg fluvoxamine and only 10mg of clomipramine and it worked wonders.Finally, as an introduction to the marvellous Ken Gillman I recommend his online-article 'Tricyclic antidepressant pharmacology and therapeutic drug interactions updated' (http://www3.interscience.wiley.com/cgi-bin/fulltext/121665024/HTMLSTART?CRETRY=1&SRETRY=0). His website (http://www.psychotropical.com/) is a bit... dirty, I suppose would be the right word; although hitting multiple targets, I mean, treating a variety of subjects.
Cheers to all of you.
This is the end of the thread.
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