Symptoms of Major Depression and Tricyclic Side Effects in Primary Care Patients

Abstract

OBJECTIVE:To examine the prevalence and course of symptoms resembling side effects of tricyclic antidepressants among primary care patients experiencing major depression and receiving nortriptyline pharmacotherapy. DESIGN:Prospective cohort study. PATIENTS: Seventy-five patients meeting DSM-III-R criteria for a current major depression.SETTING: Four Pittsburgh (Pa.) ambulatory health centers affiliated with residency programs. MEASUREMENTS AND MAIN RESULTS:Symptoms resembling tricyclic side effects were assessed at baseline and at monthly intervals using the Somatic Symptoms Checklist. The Hamilton Rating Scale for Depression and Diagnostic Interview Schedule were used to assess depressive severity and history of generalized anxiety or panic disorder, respectively. Symptoms resembling tricyclic side effects, including thirst (54%), palpitations (51%), and dry mouth (48%), were commonly experienced before commencing pharmacotherapy. Patients with severe depressive episodes and those with a history of an anxiety or panic disorder had significantly more physical symptoms than those with milder episodes of depression and were more likely to drop out of care ( n ‫؍‬ 25) before completing the acute phase of pharmacotherapy. Patients who completed the acute phase of pharmacotherapy and those who entered its continuation phase ( n ‫؍‬ 43) experienced significant reductions in many depressive and physical symptoms ( p Ͻ .001). CONCLUSIONS:Symptoms resembling tricyclic side effects are common among depressed primary care patients before beginning pharmacotherapy and generally remit with the depressive episode. Better awareness of major depression's somatic effects and the consequences of therapy could result in better management of both physicians' and patents' expectations regarding antidepressant pharmacotherapy. ajor depression is experienced by 6% to 8% of primary care patients, 1 and is associated with significant psychic distress and functional disability. 2-5 A metaanalysis of randomized clinical trials by the Depression Guideline Panel of the Agency For Health Care Policy and Research concluded, however, that most episodes of this disorder can be resolved efficaciously when antidepressant medications are prescribed at proper dosages and for adequate durations. 6 Thus, it is of concern that primary care physicians often prescribe these drugs at dosages too low to achieve therapeutic benefits and for periods too brief to prevent relapse. [7][8][9][10][11] The rationale guiding prescribing practices of primary care physicians has been the subject of much speculation. One possibility for why antidepressant medications, particularly of the tricyclic type, are prescribed at subtherapeutic dosages is that they produce disturbing side effects for patients who already are highly sensitive to the psychological and somatic symptoms associated with their depressive illness. Medication-induced discomforts such as thirst, dry mouth, palpitations, and dizziness, which are most marked early in the course of treatment, could lead ...

Not All Side Effects Associated With Tricyclic Antidepressant Therapy Are True Side Effects

“…Our results are consistent with the evidence that patients with moderate to severe FGIDs rather than patients with milder FGIDs report more symptoms possibly due to a greater tendency to set higher sensory thresholds; this has been reported for other conditions in the primary care 13, 16 and psychiatric literature 14. Possibly, some patients may not even be aware that the symptoms they attribute to the medication often were present before initiation of therapy.…”

“…This may relate to co-morbidities related to the disorder9, 10 or the influence of psychosocial distress enhancing the intensity, frequency or even the numbers of symptoms via central amplification 3, 8, 11, 12. Thus, differentiating side effects of TCAs from other somatic symptoms often reported by these patients becomes a difficult task as this may either reflect patient’s general tendency to report somatic symptoms, or amplification of this tendency by the underlying psychosocial distress 13. This phenomenon, first reported among depressed patients seen in psychiatry 14, 15 and primary care13, 16, 17 has not been adequately studied in patients with functional GI disorders.…”

“…Thus, differentiating side effects of TCAs from other somatic symptoms often reported by these patients becomes a difficult task as this may either reflect patient’s general tendency to report somatic symptoms, or amplification of this tendency by the underlying psychosocial distress 13. This phenomenon, first reported among depressed patients seen in psychiatry 14, 15 and primary care13, 16, 17 has not been adequately studied in patients with functional GI disorders. This distinction is clinically relevant since it may affect the patient’s adherence to treatment and the physician’s prescribing behaviors.…”

The Bypassing the Blues Treatment Protocol: Stepped Collaborative Care for Treating Post-CABG Depression

“…Although distinguishing true medication side effects from symptoms of the underlying mood or cardiac condition can be difficult, it was important to do so because somatic complaints resembling medication side effects often remit after resolution of the underlying depression (72). Therefore, our care managers made extensive efforts to have patients continue their antidepressant medications for at least 4 to 6 weeks so as to permit a potential treatment response to occur in keeping with guideline-recommended practice (69).…”

Use of Psychopharmacological Agents for Functional Gastrointestinal Disorders

“…If suspicions regarding mechanisms of side effects in many patients with functional gastrointestinal disorders are correct, then this is one unusual situation in which a medication has the therapeutic potential to negate its own initial side effects. 74 …”