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Melancholya

Looking for general info/experiences on tricyclics

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Hello all. 

I have been on various ssris for the past 12 years with limited success. Most recently tried escitslopram + aripiprazole, dropped the aripiprazole after a while cos it didn't bring much (if any) benefit and felt yuck. So am just back on 20mg of escitalopram. 

My psychiatrist wants to try me on TCAs but hasn't yet because I am breastfeeding and he said they're not safe. However my daughter is over 3 and my general doctor (a breastfeeding mother herself) pointed me to some info on TCAs actually being considered safe in breastfeeding. And since my daughter is 3 she can metabolise drugs a lot better than an infant (the studies on safety are all done on newborns and infants). She is encouraging me to talk to my psych about trying TCAs anyway, so I would like to do that. 

I am just wanting to hear from those who have tried TCAs and how you found them. I have atypical depression, characterised by overeating, oversleeping, lack of motivation and interest, constant fatigue. Are TCAs likely to be a good option for me after ssris have failed? 

And side effects - do they affect sex drive the way ssris do? 

Any information is hugely appreciated. I am in a deep dark hole right now and desperate to get out. 

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Have you tried SNRI(s)?

The noradrenaline action is activating, which is probably a good option for your type of depression.

Wellbutrin (with or without SSRI) is also an option I'd look into before going on a TCAs

TCAs generally have more side-effects because they hit a lot more receptors than SSRIs/SNRIs. They may also cause sexual side effects as SSRIs (“may” because they “should” but you may react differently to different meds).

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Thanks Hydrocat. Wellbutrin isn't an option for depression here unfortunately. I have tried venlafaxine in the past but it was probably 10 years ago. I might ask about trying it again. 

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Before I was dx’d BP, I tried desipramine. Found it to be extremely activating (I.e., sleep immediately was no longer an option), but it might be worth a try for depressive oversleeping. 

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Posted (edited)

I found an article on antidepressants for breastfeeding mothers:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902256/

Now this is a pretty long article, but according to the article, the TCAs that are safest to use while breastfeeding are nortriptyline (Pamelor) and imipramine (Tofranil)......The article also mentions the SSRIs sertraline (Zoloft), and paroxetine (Paxil), as relatively safe to use.......I realize that your daughter is 3 years old, and not an infant, but thought this info would be of some help......

Quote from article:

"Sertraline and paroxetine (among SSRIs) and nortriptyline and imipramine (amongTCAs) are the most evidence-based medications for use during breastfeeding because of similar findings across multiple laboratories, usually undetectable infant serum levels and no reports of short term adverse events."

Edited by CrazyRedhead
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Thank you everyone, I really appreciate these responses. 

I am not really convinced tricyclics will help for my kind of depression, but I don't know. I guess it's just worth a try. I'll also ask about duloxetine, I'm just not sure it's available here. 

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I took imipramine (Tofranil) for a while. I can't say it made much of an impact on my depression, but I didn't have trouble with side effects either. The only thing was that it was the first time in years I was able to reliably sleep without a sleep aid. Not that it made me groggy or tired or anything - I could just... fall asleep at bedtime, and stay asleep through the night. 

I have chronic suicidal ideation, and my pdoc (who knows me very, very well) would not let me have more than 2 weeks of imipramine on hand. I don't tend to think about OD-ing (which she knows), but her position was the same regardless. After a while, I got her to rx 30 days at a time as long as I agreed to let a friend pick it up and hold it for me, filling a med box for me weekly. It was annoying, but *shrug*

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Have you tried Wellbutrin ? That would be a reasonable next step. I would save the TCA for after  once you have failed more meds.

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I too have atypical depression and have tried all the tricyclics except imipramine. I found that tricyclics come with a lot of side effects. All the while I was on them I felt spaced out. Also, I was very sedated and slept a lot. The sedation never went away for me like it did for Remeron. I found that even the tricyclics which are supposed to be stimulating were sedating to me. It was a monumental struggle to get up in the morning.

Now some people swear by tricyclics. My aunt was one who did well on Elavil. They are good meds with a proven track record. However, I would not want to take a tricyclic until I tried every other antidepressant out there with the possible exception of the MAOIs.

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On 3/16/2019 at 8:22 AM, jt07 said:

I too have atypical depression and have tried all the tricyclics except imipramine. I found that tricyclics come with a lot of side effects. All the while I was on them I felt spaced out. Also, I was very sedated and slept a lot. The sedation never went away for me like it did for Remeron. I found that even the tricyclics which are supposed to be stimulating were sedating to me. It was a monumental struggle to get up in the morning.

Now some people swear by tricyclics. My aunt was one who did well on Elavil. They are good meds with a proven track record. However, I would not want to take a tricyclic until I tried every other antidepressant out there with the possible exception of the MAOIs.

Out of curiosity, what HAS worked for you? have you found anything?
EDIT: sorry, I only just noticed your signature which has your current meds in it. 

On 3/16/2019 at 6:45 AM, notloki said:

Have you tried Wellbutrin ? That would be a reasonable next step. I would save the TCA for after  once you have failed more meds.

I think it's only prescribed as a smoking cessation drug here, but I will ask my psych if I can get it. I am a little worried about the risk in breastfeeding, and my psych knows next to nothing about breastfeeding, so it's hard to get him to let me try things.

Edited by Melancholya

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52 minutes ago, Melancholya said:

Omg you guys, my psych has prescribed me bupropion/Wellbutrin! I have wanted to try this med for years. I hope it works out for me. 

Great!!! What type/dose? Good luck!!

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3 minutes ago, Iceberg said:

Great!!! What type/dose? Good luck!!

Sustained release, starting at 150mg once a day (he recommended night) and then going up to 150mg twice a day after a few days. I'm starting to get really anxious though about breastfeeding. The limited data indicates there shouldn't be a problem, but my anxiety disorder voice is whispering "what if?". I am going to try weaning I think. 

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10 hours ago, Melancholya said:

Sustained release, starting at 150mg once a day (he recommended night) 

I am not the doc, but Wellbutrin is pretty activating for the vast majority of people, so most people take it in the morning.

I used to take the sustained release (SR),  and took 150mg in the morning, and 150mg at lunch........My doc said take the second dose no later than 2pm, because it could cause insomnia if taken later in the day.

Now I take the extended release version (XL) 300mg, and I take it in the morning.........Just a little surprised that your doc recommended taking it at night, because it's famous for being activating.

Perhaps you could call your doc back and ask him why he recommends taking at night?

Edited by CrazyRedhead
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Wellbutrin is generally activating.

From my experience, it initially made me sleepy at 150 mg XL. Even cut down my anxiety somewhat.

Lasted about a week then has caused insomnia since. Trazodone handles that however.

Since you're not in the US, perhaps a RIMA might be a good fit. Moclobemide apparently does not have weight gain or anticholinergic properties.  Doesn't have the strict dietary restrictions that a MAOI would have

 

 

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MAOIs tend to be good for atypical depression, whereas TCAs tend to work best for melancholic depression. It's not a bad thing to "skip" the TCAs and go to a MAOI for this reason.

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7 hours ago, CrazyRedhead said:

I am not the doc, but Wellbutrin is pretty activating for the vast majority of people, so most people take it in the morning.

I used to take the sustained release (SR),  and took 150mg in the morning, and 150mg at lunch........My doc said take the second dose no later than 2pm, because it could cause insomnia if taken later in the day.

Now I take the extended release version (XL) 300mg, and I take it in the morning.........Just a little surprised that your doc recommended taking it at night, because it's famous for being activating.

Perhaps you could call your doc back and ask him why he recommends taking at night?

It's confusing, because the pamphlet that came with it says may cause sleepiness, but as Argh said, maybe that's an initial side effect that wears off. So maybe he recommended night time for that reason, until I go up to the 2x a day dose. I want an activating drug because I feel so tired all the time, and I sleep heaps when I'm down. But yeah obviously I don't want to stop sleeping... I will just have to see how it goes.

1 hour ago, mikl_pls said:

MAOIs tend to be good for atypical depression, whereas TCAs tend to work best for melancholic depression. It's not a bad thing to "skip" the TCAs and go to a MAOI for this reason.

I think my psych does not want me to even touch MAOIs while I'm breastfeeding. 

2 hours ago, argh said:

 

Since you're not in the US, perhaps a RIMA might be a good fit. Moclobemide apparently does not have weight gain or anticholinergic properties.  Doesn't have the strict dietary restrictions that a MAOI would have

 

 

I have asked about moclobemide before (also because it sounds likely it would be OK while breastfeeding) but he said in his experience it's not a very effective drug, and I have read things to that effect too. But, if I'm correct in my thinking, isn't it true that melancholic depression is more common than atypical? I wonder if it he finds it less effective because the majority of his patients would be melancholic? Anyway I'm just speculating. 

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Atypical depression is the more common one. It is what most have.

Two or more of the following features, present for most of the time, for at least two weeks:
  1. Increased appetite
  2. Increased sleep
  3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
  4. Interpersonal rejection sensitivity (not limited to episodes of mood disturbance) resulting in significant social or occupational impairment

Atypical depression is the most common form of depression seen in outpatient clinics in psychiatry.9 The prevalence of atypical depression based on DSM-IV criteria among samples of subjects with major depressive disorder or dysthymia has been reported to be around 40 percent.10–12 Most of the studies have shown the prevalence of atypical depression to be around four times more common in female patients.10,13,14

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990566/

Melancholic depression features decreased appetite and decreased sleep (insomnia)

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I don't know if the instant release is available in your country, but in terms of insomnia, it was better than 300mg of XL that i take.

With IR however, I would get really sleepy about 1 hr after a dose. If you respond well to wellbutrin, hopefully there's bot IR and XL as options for you to take.

FWIW, with the exception of eating more, my depression hits all the other symptoms of atypical.

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