Tricyclic and tetracyclic drugs: Pharmacology, administration, and side effects
- Michael Hirsch, MD
Michael Hirsch, MD
- Instructor in Psychiatry
- Harvard Medical School
- Robert J Birnbaum, MD, PhD
Robert J Birnbaum, MD, PhD
- Assistant Professor of Psychiatry
- Harvard Medical School
The use of tricyclic and tetracyclic antidepressants to treat depression began with reports in 1958 that imipramine was particularly effective for melancholic depression, marked by symptoms such as psychomotor retardation, anergia, dysphoria, hopelessness, and diurnal variation [1,2]. Many other cyclic antidepressants were subsequently developed, including the tricyclics amitriptyline, amoxapine, clomipramine, desipramine, doxepin, nortriptyline, protriptyline, and trimipramine, as well as the tetracyclic antidepressant maprotiline. These cyclic compounds became first-line treatment for depression for the next 30 years, until the selective serotonin reuptake inhibitors were introduced.
Clinicians use tricyclic antidepressants to treat many other psychiatric disorders besides depression, including panic attacks, generalized anxiety disorder, post-traumatic stress disorder, bulimia nervosa, and smoking cessation. Tricyclics are used to treat a variety of chronic pain states such as chronic daily headache and neuropathy. See appropriate topic reviews.
This topic reviews the pharmacology, administration, and side effects of tricyclic and tetracyclic antidepressants. Switching and discontinuing antidepressants, the pharmacology, administration, and side effects of other antidepressant classes, choosing an antidepressant for the initial treatment of depression and treatment of resistant depression, and management of tricyclic overdose are discussed separately.
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- STRUCTURE AND FUNCTION OF CYCLIC ANTIDEPRESSANTS
- PRESCRIBING CYCLIC ANTIDEPRESSANTS
- General principles
- - Dose
- - Administration
- - Plasma levels and therapeutic response
- - Discontinuing tricyclics
- Specific cyclic drugs
- - Amitriptyline
- - Amoxapine
- - Clomipramine
- - Desipramine
- - Doxepin
- - Imipramine
- - Maprotiline
- - Nortriptyline
- - Protriptyline
- - Trimipramine
- SIDE EFFECTS
- Bone fractures
- Other side effects
- BASELINE TESTING AND MONITORING FOR SAFETY
- Cardiac evaluation
- Other monitoring
- INFORMATION FOR PATIENTS