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• Click "Print this page" on the left hand side to print the whole section
• Download a handy PILL (Patient Information Leaflet), a two-page summary of the main questions and answers from here. This can then be printed.

There are many other Patient Information Leaflets (PILs) across the world for patients and carers. There are also official information leaflets (often called a Data Sheet, Package Insert, or Summary of Product Characteristics). They are not on our site, so we can't take any responsibility for them but you can click here for links to other sites and leaflets

^{Updated 12.11}

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The tricyclics can help to treat the symptoms of:

• Depression, their main use
• OCD (Obsessive Compulsive Disorder), but only clomipramine
• Panic disorder
• PTSD (Post-Traumatic Stress Disorder

The tricyclics can also sometimes be used to help the symptoms of:

• ADHD (Attention Deficit Hyperactivity Disorder)
• Anxiety (GAD or Generalised Anxiety Disorder) in the short-term
• Bipolar depression with mood stabilisers
• Eating disorders
• Insomnia in low dose
• Seasonal Affective Disorder
• Social anxiety

Tricyclics can also be used for neuropathic pain (caused by nerve damage) and for nocturnal enuresis (bed wetting).

There are other treatments for the conditions above. The main ones are included in the section on each of the conditions above.

^{Updated 10.11}

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The usual effective dose of clomipramine for depression should be 125-150mg a day*. It should be started at 10-25mg a day for a few days and increased every few days up to 125-150mg a day (perhaps up to 250mg a day). This can be taken all as one dose (usually at night) or split up during the day.

For OCD and phobias, the dose should start at about 25mg a day and then increase up to 125mg-150mg a day, sometimes up to 250mg a day or higher.

It is not recommended for children under 18 years of age.

* there are about 1 in 100 people who have an extra enzyme in the liver that breaks down amitriptyline quicker. This doesn't make any difference the rest of the time but does mean that person will need a much higher dose. There are also about 1 in 30 people who don't have the enzyme in the liver and so don't break down amitriptyline. Again that doesn't make any difference the rest of the time but will mean that person needs a lower dose and may get lots of side effects. However, 24 out of 25 people have the common enzymes and so will still need the full dose. 

^{Updated 10.11}

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This will rather depend on that you are taking it for. To help you choose, click on the links for the main options (self-help and help from others), the main medicines, and a handy chart comparing the main medicines:

• Depression - main options, main medicines and handy chart
• ADHD - main options, main medicines and handy chart
• Anxiety - main options, main medicines and handy chart
• Bipolar depression - main options, main medicines and handy chart
• Eating disorders - main options, main medicines
• Insomnia - main options, main medicines and handy chart
• OCD - main options, main medicines and handy chart
• Panic disorder - main options, main medicines and handy chart
• PTSD - main options, main medicines and handy chart
• Seasonal Affective Disorder - main options, main medicines and handy chart
• Social anxiety - main options, main medicines and handy chart

There are other treatments for the conditions above. The main ones are included in the section on each of the conditions above.

^{Updated 10.11}

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The brain has many naturally occurring chemical messengers. Two of these are called serotonin (sometimes called 5-HT) and noradrenaline. Both are important in the areas of the brain that control or regulate mood and thinking. It is known that these two chemical messengers are not as effective or active as normal in the brain when someone is depressed. Tricyclic antidepressants increase the amount of these chemical messengers in the brain. This can help correct the lack of action of these messengers and help to improve mood. The tricyclics can also effect another chemical in the brain called "acetylcholine" and this is the cause of some of their side-effects.

^{Updated 8.11}

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Take your tricyclic as directed on the medicine label. Try to take it at regular times each day. Taking it at mealtimes may make it easier to remember as there is no problem about taking any tricyclic with or after food. If the instructions say to take them once a day this is usually best at bedtime as they may make you drowsy at first. They are not, however, sleeping tablets.

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Tablets and capsules:
Tablets and capsules should be swallowed with at least half a glass of water whilst you are sitting or standing. This is to make sure that they reach the stomach and do not stick in the throat.
Liquids:
Your pharmacist should give you a medicine spoon or oral syringe. Use it carefully to make sure you measure the correct amount. Ask your pharmacist for a medicine spoon if you do not have one. Shake the bottle well before use as the drug can settle to the bottom and cause you to get too low a dose at the start and too high a dose at the end of the bottle. Your mouth may feel a little numb after taking one of these liquids as it can have a local anaesthetic effect. This is common and nothing to worry about.

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This may depend on what you are taking a tricyclic for. Click the link below for the answer for that condition:

• ADHD
• Anxiety (GAD or Generalised Anxiety Disorder)
• Bipolar depression
• Depression
• Eating disorders
• Insomnia
• Obsessive Compulsive Disorder
• Panic disorder
• PTSD (Post-Traumatic Stress Disorder)
• Seasonal Affective Disorder
• Social anxiety

Generally, it may take as long as two weeks or more before the tricyclics start to work for most of these conditins, and a further three or four weeks for the full effect to be felt. Unfortunately in some people the effect may take even longer to occur e.g. several months, especially if you are older.

^{Updated 10.11}

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This will depend on what you are taking it for. It may also depend on how unwell you have been or how severe the symptoms have been, as people respond differently. Click on the link below for the answer for that condition:

• ADHD
• Anxiety (GAD or Generalised Anxiety Disorder)
• Bipolar depression
• Depression
• Eating disorders
• Insomnia
• Obsessive Compulsive Disorder
• Panic disorder
• PTSD (Post-Traumatic Stress Disorder)
• Seasonal Affective Disorder
• Social anxiety

^{Updated 10.11}

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Tricyclics are not "addictive" as such (e.g. no one abuses them), but if you have taken them for eight weeks or more you may get some "discontinuation" effects if you stop them suddenly. These do not mean that the antidepressant is addictive. For a drug to be addictive or produce dependence, then it must have a number of characteristics:

• should produce craving for the drug when the last dose "wears off"

• there should be a "reward" (e.g. a good feeling) from taking the drug

• should produce tolerance ie you need more drug to get the same effect

• should produce withdrawal symptoms specific to that drug.

These characteristics come from the World Health Organisation. Tricyclics have none of these and so are not addictive. If stopped suddenly, may produce some "discontinuation" symptoms but these are probably more of an "adjustment" reaction from sudden removal of a drug rather than "withdrawal". It would be fair to say that not everyone agrees with this.

Click here to read a bit more about this, where you can find our thoughts on this knotty problem.

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Start again as soon as you remember unless it is almost time for your next dose, then go on as before. Do not try to catch up by taking two or more doses at once as you may get more side-effects. You should tell your doctor about this next time you meet.

If you have problems remembering your doses (as very many people do) ask you pharmacist, doctor or nurse about this. There are some special packs, boxes and devices which can be used to help you remember. You can try leaving the pack somewhere you will see it each day e.g. in the bathroom, kitchen, in a car etc.

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It is unwise to stop taking a tricyclic suddenly, even if you feel better. Two things could happen. Firstly, your symptoms can return if treatment is stopped too early (see "How long will I need to keep taking them for?"). Secondly, you might also experience some mild "discontinuation" symptoms (see also above). At worst, these could include headache, restlessness, diarrhoea, nausea, 'flu-like symptoms, lethargy, abdominal cramps, sleep disturbance and mild movement disorders. They can start shortly after stopping or reducing doses, are usually short lived, will go if the tricyclic is started again, and can even occur with missed doses.

If you get these discontinuation symptoms, you have a number of options:

• If they are not severe, you can wait for the symptoms to go - they usually only last for a few days or weeks

• Ask for something to help your symptoms in the short-term e.g. a sedative or sleeping tablet

• Start the medication again (the symptoms should go) and then try reducing the dose more slowly over a longer time e.g. reduce the dose by about a quarter (25%) every 4-6 weeks
  Switch to another antidepressant - this sometimes helps

When the time comes your doctor should withdraw the tricyclic slowly e.g. by reducing the dose gradually every few weeks. You should discuss this with your doctor.

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The table below shows about some of the side effects you might get with a tricyclic.

Do not be worried by this list of side effects. Some people get no side effects at all and others may get some effects that are not listed in this table. Side effects tend to be worse with higher doses. Starting with a lower dose sometimes helps. If you think you might have a side effect to your medicine, you should discuss this with your doctor, nurse of pharmacist. You should also see the manufacturer's information leaflet.

^{Updated 12.11}

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The tricyclics may make you feel drowsy or sleepy. This is partly because they have an antihistaminic effect (like the older antihistamines for hay fever). You should not drive (see below) or operate machinery until you know how they affect you. You should be careful as they may affect your reflexes reaction times. They are not, however, sleeping tablets, although if you take them at night they may help you get to sleep.

^{Updated 11.11}

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Although a few people can lose weight on tricyclics, some gain weight. This is partly due to an increase in appetite and/or a craving for sweet food caused by the tricyclics. It may also be that the tricyclics slow down your body metabolism, so that you do not metabolise food as quickly. So, not only do you eat more, you use the food less well. It is impossible to know what the effect on your weight may be because each person will be different. Unfortunately all the tricyclic antidepressants seem to have the same effect.

If you do start to put on weight or have problems with your weight, your doctor can arrange for you to see a dietician for advice. Any weight you put on can be controlled while you are still taking this medication, with expert advice about diet. In some people this weight gain can be a serious problem. If it causes you distress make sure your doctor knows about this. A change in drug e.g. to a different type of antidepressants, or change in dose may be necessary in extreme cases. Your doctor can arrange for you to see a dietician.

Click here for a few tips on how to help you feel less hungry and lose weight.

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Drugs can affect desire (libido), arousal (erection) and orgasmic ability. The tricyclics are know to affect all three stages in some people. Lack of desire and delayed orgasm is known to occur (although the opposite has been reported rarely as well). If this does seem to have happened, you should discuss this with your doctor, as a change in dose, timing or medicine may help any problem. Any problem is reversible. However, if you are taking trazodone for depression, two studies have shown that having depression is more likely to affect your sex-life than an antidepressant ^{(eg Lanza di Scalea 2009)}.

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You should have no problem with any foods or drinks, other than alcohol (see separate question).

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Whether or not it is safe to drink alcohol with any medicine will depend on:

• How much you have to drink e.g. the amount and over how long
• What you then try to do (e.g. sleep or drive)
• If you have any other conditions e.g. asthma or a chest infection (as alcohol can make it harder to breathe), epilepsy
• If you are taking any other medicines

Alcohol reaches all parts of the brain and can affect many things e.g. thinking, reactions and breathing. Alcohol can also boost the effect of GABA (the brain's main calming chemical messenger).

It is not safe to drive after drinking alcohol, with or without a tricyclic. Some countries allow driving after a small amount of alcohol but others have a zero tolerance. The UK has the highest limit in Europe, France lower, Scandanavia even lower and zero in some Eastern European countries. It is not possible to say what blood level you might have from a drink so it is safest not to drink if you know you may have to drive. It is taken as a very serious offence in most countries. You should see National Guidelines, laws and regulations in the country in which you are driving.

^{Updated 11.11}

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The tricyclics have many interactions with other medicines:

• Tricylics can cause drowsiness so if taken with benzodiazepines (e.g. diazepam, lorazepam, temazepam), older antihistamines, benzodiazepines (e.g. diazepam, lorazepam, temazepam), melatonin or alcohol, it will cause more drowsiness
• Tricyclics have anticholinergic effects (e.g. dry mouth, blurred vision) so be careful if taken with sedative antipsychotics (e.g. pericyazine, chlorpromazine, olanzapine, quetiapine)
• Tricyclics have cardiac effects (so be careful if used with amiodarone or disopyramide)
• Most tricyclics increase the amount of serotonin in the brain so should not usually be taken with similar drugs, e.g. SSRIs (e.g. citalopram, fluoxetine, paroxetine, sertraline), moclobemide, MAOIs (e.g. phenelzine, isocarboxazid, tranylcypromine), trazodone, St. John's wort, venlafaxine, duloxetine or trazodone.
• The effects of tricyclics can sometimes be increased by some antipsychotics (e.g. haloperidol), aspirin, calcium-channel blockers (e.g. diltiazem, verapamil), fluconazole, cimetidine, some SSRIs (e.g. fluoxetine, paroxetine), terbinafine or methylphenidate
• The effect of tricyclics can be decreased by phenylephrine and some other treatments for colds and ‘flu

This does not necessarily mean that this will happen in everyone or that some of these medicines can not be used together. It is just that you may need to follow your doctor's instructions very carefully. There are many other possible drug interactions (e.g. you can try an external on-line drug interactions checker, although this is nothing to do with our site).

^{Updated 1.12}

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Cigarette smoke contains over 3000 different chemicals. Some of these chemicals can make some of the enzymes in the liver work faster (called "enzyme induction" of e.g. CYP1A2 or P4501A2). This means that any medicine those enzymes break down will be broken down quicker. So, you'll end up with less of that medicine if you smoke. And also you will have more of it in the body if you stop smoking. However, the tricyclics do not seem to be affected so there seem to be no extra problems if smoking with a tricyclic.

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By including this section, we're not saying it's right to take illicit or illegal drugs, because it isn't. We're just trying to answer the questions as best we can under the circumstances. With illicit drugs, the full answer is usually that we don't really know. So, we can only go on a few studies, a few reports and what we know about the drugs themselves.

Cannabis (illegal in most countries):

Smoking cannabis increases the amount of dopamine in the pleasure centres of the brain, which is where the reward or buzz comes from. However, psychosis also comes from having too much dopamine in another area of the brain. You have to remember that cannabis can increase dopamine in all areas of the brain and so can make psychosis worse. Please be careful, everything in moderation and if dope makes you worse, keep off the grass. It really won't help you in the long-term. Don't forget that if you're a toker, you're also a smoker, so see the question above.

The tricyclics can be a problem with cannabis so smoking dope while taking a tricyclic is not a good idea. You may have more dry mouth, blurred vision and finding it hard to pass water (wee), There are also many reports of increased heart rate, and delirium (confusion).

Cocaine (illegal in most countries)

Cocaine is of course highly addictive and has many adverse or side effects on the body and brain. It can make most mental health symptoms worse in the long-term. However, there are no reports of extra problems with a tricyclic and cocaine, although this doesn't mean it's safe.

Ecstasy (illegal in most countries)

Ecstasy has many effects on the brain, the main ones producing the high seem to be by boosting serotonin, noradrenaline and dopamine in the brain. While it can cause a high, the effect wears off fairly quickly. It seems that the toxic effects on the brain are cumulative i.e. the more tablets you have over your lifetime, the more chance you have of having damage to the brain e.g. long-term depression and poor memory. However, there are no reports of extra problems with the tricyclics and ecstasy, but again this doesn't mean it's safe.

Opiates

The opiates include many chemicals, some of which are used in medical care (e.g. codeine for diarrhoea and stopping coughs, diamorphine and morphine for pain). However, there are no extra problems reported from taking opiates (e.g. heroin, methadone, codeine) with the tricyclics, although you might feel more drowsy.

^{Updated 1.12}

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You should have no problems with "The Pill" and any of the tricyclics.

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In the UK, Levonelle one step® is available and is usually known as 'the morning after pill'. It is taken to reduce the chances of becoming pregnant after unprotected sex or failure of a contraceptive method. In fact "Emergency Contraception" is the better term because it can be taken up to 72 hours (3 days) afterwards. It can be bought over-the-counter without a prescription from pharmacies. EllaOne® tablets (which may work up to 5 days afterwards) and a coil (Intra-uterine device) can also be used but must be prescribed by a Doctor.

If you are taking a tricyclic, the usual dose should work if you follow the instructions carefully.

N.B. We accept that for religious, cultural or ethical reasons some people do not approve of, or agree with, the use of the "Morning After" pill. However, we have answered the question because it is one of the most often asked of NHS Direct in UK, and they suggested we include it.

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Several female functions such as menstrual cycle (e.g. your periods) are controlled by a hormone called prolactin. Prolactin in the body rises during and after pregnancy and this triggers the body to make breast milk. The amount of prolactin in the body is kept in control by one part of the brain (the tuberoinfundibular system if you want to know). This area of the brain uses dopamine as its chemical messenger. Some medicines (especially antipsychotics) block the effect of dopamine in the brain. This is just what we want to help reduce some of the symptoms caused by too much dopamine e.g. psychosis, paranoia. However, if these medicines also block dopamine in the area of the brain that keeps prolactin under control, prolactin can get out of control and increase. Higher than usual levels of prolactin in the brain and blood will stop your periods (or at least make them irregular or unpredictable). Much higher levels can lead to your breasts leaking milk or lactating (the medical term is galactorrhoea). The name of the hormone (prolactin) might help you guess this anyway i.e. pro- (meaning for) -lactin (as in lactation).  High prolactin can make it more difficult to become pregnant, and over many years can have an effect on your sex-life, and maybe even your bones.

The tricyclics don't usually have any effect on dopamine in this part of the brain and so should not have any effects on your periods. However, this can happen rarely e.g. if you are on a high dose or are sensitive to the tricyclics. So, if your periods are irregular or late, or you start leaking milk, then you should see your doctor about this to find if there are any other causes. If your tricyclic seems to be the cause, the usual thing to do is switch to another similar medicine. Reducing the dose doesn't usually work.

^{Updated 11.11}

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It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs.

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine.

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press.

It may be helpful to know that in the USA, the FDA (Food and Drug Administration) classifies medicines in pregnancy in five groups:
A = Studies show no risk, so harm to the unborn child appears only a remote possibility
B = Animal and human studies indicate a lack of risk but are not fully conclusive
C = Animal studies indicate a risk but there is no safety data in humans
D = a definite risk exists but the benefit may outweigh the risk in some people
X = the risk outweighs any possible benefit

The tricyclics are classified as either "C" or "D" (amitriptyline "C", clomipramine "C", doxepin "B", nortriptyline "D" and trimipramine "C"). The others are not available in the USA and so are not classified. One large study showed no evidence of a teratogenic effect and no increase in spontaneous abortions, although another study showed a very slightly increased rate of problems. Animal tests show a low risk of danger but some problems have been reported and so you should seek personal advice from your GP, who may then if necessary seek further specialist advice. There have been some reports of discontinuation effects (e.g. jitteriness) in the newborn child and so it may be possible to reduce your dose a bit before your due date. A recent study has shown no evidence of any short or long-term effects on intelligence and language development, although there was a slight reduction in the length of pregnancy (by about 6 days).

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Almost every medicine passes into breast-milk. The main questions are how much and if this is likely to have an effect on your baby. But also remember that being ill (e.g. depressed, manic, psychotic) may have more harmful and lasting effects on you and your child (such as bonding and behaviour e.g. Field, 2010) than a small amount of an effective medicine. If you have been taking a medicine while you are pregnant, you should usually be able to carry on as the amount in breast-milk is much less than the baby would have got while you were pregnant. It is usually thought to be fairly safe if the baby gets less than 10% of the mum's dose. But there may be times when although a medicine gets into breast milk the benefit may be worth the risk, so you should seek personal advice on this.

If you stop any medicine suddenly, some people can get discontinuation or withdrawal symptoms (see question above). If you have been taking a medicine during pregnancy, the same can sometimes happen to the baby when born. If the drug gets into breast milk, this can reduce the effect of suddenly not having the medicine (as well as coping with being in the big wide world too).

If you want to breast-feed there are some things you can do to reduce any risk:

• Nearly all medicines can be taken once a day. So, taking your daily dose just before the baby's longest sleep (often this will be at night) will reduce the amount the baby gets from the milk.

• Any side effects in the baby will be higher if the mum is taking a higher dose. So, try to take the lowest dose possible to still get an effect.

• Try not to take any medicines you don't really need. This includes any medicines you might buy over-the-counter

• Make sure your nurse, health visitor or doctor checks your baby for any side effects e.g. being extra sleepy, having colic, feeding problems, being floppy or poor weight gain. If there are any problems you might need to switch medicines or drop your dose a bit

• Hind milk (the second half of the feed) is likely to contain slightly more of any medicine than the first half

• Avoid new medicines if possible as there is less information about them and breast-feeding.

You must be extra careful of any medicines if your baby was pre-mature, or has kidney, liver, heart or brain problems.

We know that some tricyclics get into breast milk but this is probably only at low levels (less than 1% for most of them, well below the 10% "safe" level) and seems to be of low risk. If you want to take a tricyclic, you should talk about this to your doctor, nurse or health visitor because they will be able to do regular checks on your baby to make sure there are no problems e.g. poor feeding, heart problems, colic or drowsiness. The exception is that you should not breast-feeding if you are taking doxepin - try another tricyclic. Clomipramine might be best avoided too. Amitriptyline and imipramine may be the safest. 

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The tricyclics can affect your driving in two ways. Firstly, you may feel drowsy and/or get blurred vision at first when taking any of the tricyclics. Secondly, the tricyclics can slow down your reactions or reflexes. This is especially true if you also have a dry mouth, blurred vision, constipation etc. (the so-called "anticholinergic side effects"). Until these wear off, or you know how your tricyclic affects you, do not drive or operate machinery. You should be careful as they may affect your reaction times or reflexes even though you feel well.

If you are taking any medicines, the rules about driving will depend on the country you’re driving in. Click on the links below for advice:

• Medicines and driving in the UK (England, Scotland, Northern Ireland and Wales)

• Medicines and driving in the Republic of Ireland

General advice on driving safely

If you want to drive, you should take sensible steps to reduce any risk. These could include:

• Avoid driving when you are tired or ill
• Do not drive after having any alcohol as this can make any drowsiness worse (a third of all fatal road traffic incidents involve alcohol-dependent drivers)
• Avoid driving at night, dusk or in bad weather
• Avoid motorways, dual carriageways and the rush hour
• Give yourself plenty of time. Don’t rush
• Be extra careful if you have not slept well the previous night

As some medicines can affect your driving, be extra careful:

• If starting a new medicine
• After a change in dose (especially an increase)
• If you are on a high dose or seem very sensitive to side effects
• If you are taking any medicines for other symptoms e.g. antihistamines for hay fever or allergies
• If your medicine causes you blurred vision, drowsiness, poor co-ordination, poor attention

If you are driving less than 2000 miles a year, once you consider insurance, tax, MoT, repairs, maintenance, parking and petrol, you may actually find it is cheaper to get taxis and busses, and walk the short journeys.

^{Updated 11.11}

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Not usually. Some people who need to take higher doses occasionally need a blood test to make sure they are getting enough, but not too much, of the tricyclic.

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