Classic Antidepressants (aka TCAs) with Children and Adolescents
There are many different classes of antidepressants available in Canada. Some classes have been available for over 30 years, while others are relatively new. Traditional antidepressants, also known as “tricyclic” antidepressants (TCAs), include:
- Amitriptyline (Elavil®)
- Clomipramine (Anafranil®)
- Desipramine (Norpramin®)
- Imipramine (Tofranil®)
- Maprotiline (Ludiomil®)
- Nortriptyline (Aventyl®)
Though these medications are called “antidepressants”, they may be used for several conditions other than depression, When the benefits (e.g., reducing your symptoms) of using a traditional antidepressant outweighs the potential risks (e.g., the side effects), many doctors may prescribe one of these medications to treat:
- Anxiety disorders such as social phobia, and post-traumatic stress disorder
- Attention deficit/hyperactivity disorder (also known as AD/HD)
- Bedwetting (enuresis) (imipramine is approved by Health Canada for this use in children over 5 years old)
- Irritable bowel syndrome
- Nerve related pain disorders (e.g. migraine headaches, neuralgia)
- Obsessive compulsive disorder (also known as OCD) (clomipramine is approved by Health Canada for this use in children over 10 years old)
- Sleep disorders (insomnia)
These medications may also be used to help treat symptoms associated with other conditions such as migraines or eating disorders. Your doctor may be using this medication for another reason. If you are unclear why this medication is being prescribed, please ask your doctor.
Traditional antidepressants increase the amount of certain chemicals in the brain called serotonin and norepinephrine (as well as other brain chemicals). It is believed that these brain chemicals are not working properly well in people who are depressed. The exact way that these medications improve the symptoms of depression is still not fully known. The effect these medications have on other brain chemicals (like histamine and acetylcholine) may explain how these medications work to help improve symptoms of sleep disorders (insomnia) and bedwetting (enuresis).
Several traditional antidepressants have been studied in children and adolescents for treatment of depression, AD/HD or anxiety disorders. Though some studies support the use of certain traditional antidepressants in children and adolescents with various psychiatric or medical conditions, the majority of well-designed studies of children and adolescents with depression have found that these medications are not better at treating the symptoms of depression than a placebo (an inactive pill that looks like the medication). For treatment of depression and anxiety disorders, the addition of behavioural therapy such as Interpersonal Therapy (IPT) for depression or Cognitive Behaviour Therapy (CBT) to this medication may help to increase the potential for benefits.
Traditional antidepressants are usually taken once or twice a day. They are usually given as tablets. Amitriptyline is also available in liquid form. You can take this medication with or without food.
This medication should be taken at the same time(s) each day (usually bedtime) as directed by your doctor. Try to connect it with something you do everyday (like brushing your teeth) so that you don’t forget. Try to avoid alcohol while taking traditional antidepressants.
Usually, your doctor will start with a low dose. This dose will be slowly increased based on how you respond to it. You and your doctor can then discuss the best dosage to stay on based on how you tolerate this medication (how well the medication is working and how you are doing with the side effects of the medication) and how well it helps to decrease your symptoms.
This depends on what you are using it for. If you are using this medication for symptoms of insomnia, you may notice benefits in the first week of treatment. For most other conditions, these medications need to be taken for 3 to 6 weeks before you begin to feel better. Different symptoms may improve at different times. For example, improvements in appetite, energy, and attention may be seen within the first 2 weeks. Sometimes, others will notice improvements in you before you do. Full beneficial effects may take 4 to 8 weeks (or longer). Since this medication takes time to work, do not increase, decrease or stop it without discussing it with your doctor first.
If you are not feeling better within 6 to 8 weeks, your doctor may recommend you take a different medication. There is a small chance that depression or anxiety symptoms may worsen or that you may experience increased thoughts of self harm during the first months of taking this medication (see section on side effects). If this happens, tell your doctor IMMEDIATELY.
This depends on the symptoms you have, how frequently they occur and how long you have had them. For sleep disorders, these medications are usually only taken for a short period of time; from a few weeks to a few months. For mood and anxiety disorders, most people need to take this medication for at least 6 months. This allows time for your symptoms to stabilize and for you to regain functioning. After this time, you and your doctor can discuss the benefits of continuing treatment.
For other conditions, if you tolerate this medication well, you may be asked to take it on an ongoing basis for an indefinite amount of time. Do NOT stop taking this medication (even if you are feeling better) without discussing it with your doctor first. If you stop taking this medication suddenly, it is possible that your symptoms may return or you may have a bad reaction.
Once you have started taking this medication, you and your doctor will need to monitor for both beneficial and unwanted effects. Your doctor will check your progress and discuss changes in symptoms during the next 3 months to confirm that the medication is working properly and that possible side effects are avoided. At this time, you can discuss how long you might need to take this medication.
No, this medication is not addictive and you will not have “cravings” for it like some people might with nicotine or street drugs. If you and your doctor decide for you to stop taking a traditional antidepressant, your doctor will explain how to safely lower the dose so you won’t feel any unpleasant “flu-like” effects (chills, nausea, vomiting, dizziness, tingling in hands and feet, muscle aches, fever and electrical sensations) as your body adjusts to being without this medication.
As with most medications, side effects may occur when taking traditional antidepressants. Most side effects are mild and temporary. Sometimes, the side effects may occur before any of the beneficial effects. It is possible for some individuals to experience side effects that they feel are serious or long lasting. If this occurs, speak to your doctor about ways to manage them. Below are some of the common side effects and potentially serious side effects of taking traditional antidepressants. In brackets are suggested ways to lessen these effects.
Side effects may be more common when starting a medication or after a dose increase. If any of these side effects is too troublesome for you, please discuss them with your doctor, nurse or pharmacist.
- Blurred vision (usually disappears in 1-2 weeks; use bright lights or a magnifying glass when reading)
- Dry eyes (try using artificial tears eye drops)
- Constipation (increase exercise, fluids, vegetables, fruits and fiber intake)
- Dizziness (try getting up slowly from a sitting or lying down position)
- Drowsiness (try taking the dose at bedtime; this usually lessens over time)
- Dry mouth (try chewing sugarless gum, sour candies, ice chips, or popsicles)
- Energized/agitated feelings (avoid caffeine from energy drinks, colas and coffee)
- Excessive sweating
- Headache (try using a pain reliever like acetaminophen (plain Tylenol®))
- Increase in hunger (avoid high calorie foods)
- Stomach aches or nausea (try taking the medication dose with food)
- Unusually vivid dreams
- Weight gain (monitor your food intake, increase your exercise)
- In Adolescents/Adults: Changes in sexual performance or interest (discuss with your doctor)
Uncommon side effects (e.g., those that occur in less than 5% of patients)
Contact your doctor IMMEDIATELY if you have any of these side effects:
- Change in mood to an unusual state of excitement, irritability or happiness
- Difficulty urinating
- Irregular heartbeat
- Seizures (also called fits or convulsions)
- Skin rash, itchy skin or hives
- Thoughts of self harm, hostility or suicide
- Tingling or tremor in the hands or feet
- Uncomfortable sense of inner restlessness or agitation
Tell your doctor or pharmacist if you:
- begin taking any other new medication (prescription or non-prescription), since several other medications can interact with traditional antidepressants
- feel drowsy, dizzy or slowed down. Traditional antidepressants can make some individuals experience these temporary side effects. Traditional antidepressants may increase the effects of alcohol, resulting in more sedation or dizziness. if you feel this way, it is important to avoid operating heavy machinery or driving a car.
- have a heart condition (e.g., heart attack, congestive heart failure, irregular heart beat) or a family history of fainting, strong or irregular heart beat, or sudden death
- have a history of diabetes, thyroid disease, kidney or liver disease or seizures
- have any allergies or have experienced a reaction to a medication
- have any changes in mood or thoughts of self harm
- if you develop any new medical problem while you are taking traditional antidepressants
- miss a period, become pregnant or are trying to become pregnant or are breast-feeding
What special instructions should I follow while using traditional antidepressants?
- Keep all appointments with your doctor and the laboratory. Your doctor may order certain lab tests to check how you are responding to this medication, and to monitor for side effects.
- Do not allow anyone else to use your medication.
- You may be more sensitive to the sun than usual while taking a traditional antidepressant. Wear sunscreen (minimum SPF 30) and wear sunglasses when you first begin to use this medication.
- It is a good idea to have a visit or telephone call with your doctor within 1-2 weeks after you start taking a traditional antidepressant, and then periodically after that to see how well the medication is working, how well you are tolerating the medication, and to discuss any problems you may have.
If you take this medication only at bedtime and you forget to take it, do not take the missed dose and continue with your regular dosing schedule the next day. Do NOT double your next dose. If you take it more than once a day, take the missed dose as soon as possible. However, if it is almost time for your next dose (e.g., within 4 hours), do not take the missed dose and continue with your regular dosing schedule. Do NOT double your next dose.
- Keep this medication in the original container, stored at room temperature away from moisture and heat (e.g., not in the bathroom or kitchen).
- Keep this medication out of reach and sight of children.
Special thanks to the Kelty Centre for Mental Health for permission to adapt this document. The original document was developed by health professionals of BC Mental Health and Addiction Services, and reviewed by the staff of the Kelty Mental Health Centre. French translation provided courtesy of the Ontario Centre of Excellence for Child and Youth Mental Health.
You are free to copy and distribute this material unchanged and in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/. For any other uses, please contact the original rights holder, the Kelty Mental Health Centre.
Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.
Date of Last Revision: Mar 29, 2021