Are TCAs really better than SSRIs?

[tryp]

I had a skim through the literature, and in most studies, it looks like TCAs and SSRIs generally have about the same efficacy. So why are TCAs considered to be something good to try after a patient doesn't respond to SSRIs? Is it just in the hope that, since everyone's brain is different, TCAs will be that person's magic bullet, or is there actually something about them that makes them more likely to work than SSRIs?

[Velvet Elvis]

Some of the TCAs have more of a NA kick to them. Desipramine is almost a pure NRI. There's a video I posted a month er two back that you might want to take a look at.

http://www.crazyboards.org/forums/index.php/topic/41390-a-good-stanford-lecture-on-neuroscience-of-depression/

[Catnapper]

I'm not very knowledgeable about the medical literature, but I can give you my experience.

Prozac turned me into a zombie when I was suffering from dysthymia. So the pdoc changed me to Wellbutrin and I felt fine. Fast foward a few years to the midst of a really bad depressive episode. I was continuing the Wellbutrin, and the pdoc was looking for something to augment it with, and picked Vivactil, a tricyclic. The side effects were uncomfortable (dry mouth and constipation), but it did help me get better.

Actually the side effects were crappy enough that the pdoc had me do a mood chart, and on the following visit he had me taper off the Vivactil. When I went for my next visit, there was the proof easily visible on the mood chart that the Vivactil had been working. So I re-started it, and was on it for about a year and a half.

[conundrum]

I'm curious about trying a TCA for my anhedonia, the SSRIs don't help much except low dose prozac does something for motivation and interest, but I'm still pretty anhedonic on it. Pristiq seemed to give me some moments of color and feeling. I'm wondering if adding a TCA to low dose prozac could recapture some color. A sort of DIY cheap SNRI, more balanced towards norepinephrine

Did you notice any negative cognitive problems with vivactil? Most of the reviews I've seen of that particular TCA are very good. My pdoc is reluctant to give me a TCA because she thinks I had mood stability issues, although I've never had a manic moment in my life. Do you take bethancol with it for constipation and dry mouth?

[Catnapper]

I'm not on it these days, I was probably on it for about 18 months. I was in such a deep depression when I started it that I doubt I would have noticed any cognitive impairment. I didn't take anything for the dry mouth or constipation, although in hindsight I would have upped my water intake and gotten some metamucil as well.

I've never been manic or hypomanic.

The only problem I ever had is that other docs (like my GP) and pharmacists had never heard of it, so especially at the pharmacy it takes some advance planning as they will probably have to special order it. But once they know it's a recurring prescription, it shouldn't be any trouble, but I'd call ahead anyway just to be sure.

[null0trooper]

I had a skim through the literature, and in most studies, it looks like TCAs and SSRIs generally have about the same efficacy. So why are TCAs considered to be something good to try after a patient doesn't respond to SSRIs? Is it just in the hope that, since everyone's brain is different, TCAs will be that person's magic bullet, or is there actually something about them that makes them more likely to work than SSRIs?

Some of the TCAs affect noradrenaline as well as, or in place of, serotonin. These can be a bit more "activating" than the average person dealing with depression with anxiety and/or insomnia can tolerate Some have an antihistamine effect, ranging from "mild" to "many times stronger than diphenhydramine", and these can be heavily sedating (but can also function as antipsychotics.) Then there's amitriptyline (Elavil), which affects nearly every neurotransmitter one way or another.

The problem is that many of these can be taken in fatal overdose. Also, some of the uncommon side effects include dangerous cardiac conditions. On the other hand, the selective (and that's a relative term) serotonin reuptake inhibitors by far have a more consistent set of effects and side effects and are harder to overdose on, making them a safer first choice for most folks with clinical depression and anxiety disorders.

If your depression is really an aspect of bipolar disorder, some of the TCAs can side-step the serotonin reuptake inhibition that can make things worse. If it's driven more by noradrenaline dysfunction, or sometimes if there's comorbid ADHD, the noradrenergic TCAs are far more likely to help than an SSRI. With psychotic features or really bad insomnia, maybe one of the sedating TCAs could help more.

Conundrum: I haven't had noticeable cognitive problems as a result of desipramine (Norpramin), so I'd be surprised if Vivactil would cause many.

( Edit: like catnapper, "mania" isn't a setting my brain recognizes. Hell, my mood rarely gets higher than "fuck it all")

tl,dr version: TCAs are the crazy meds to try when the patient's crazy isn't the normal crazy.

[conundrum]

Thanks for the reply null0trooper,

I am interested in TCA, since I think the increase in norepinephrine could help in my anhedonic depression and perhaps memory and concentration. So far the only drugs that have helped at all, even if just for a few days or weeks, have worked on norepinephrine and serotonin. I'd like to combine the 5 HT2C antagonism of low dose prozac with a tricyclic and see what that does.

[hollywoodfreaks]

Conundrum, It's too bad that Wellbutrin didn't work for you. I had similar symptoms to yours when I was just taking an SSRI, but adding Wellbutrin seemed to help with some of those, especially the anhedonia. I'm guessing it's the dopamine aspect of it that helps.

[conundrum]

Yeh wellbutrin made me really tweaky, but the thing that scared me the most was the bad tinnitus it caused. I'm a musician, well before the anhedonia, and the thought of that becoming permanent scares me. I took the Teva budeprion SR, I wonder if the side effects aren't so bad with the brand. Probably wouldn't make a difference.