The older antidepressants medication tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are effective against certain kinds of depression, and are still sometimes prescribed if other antidepressants like SSRIs are not effective.
- TCAs -Tricyclic antidepressants and tricyclic-related drugs, including amitriptyline (Tryptizol), clomipramine (Anafranil), imipramine (Tofranil), lofepramine (Gamanil), nortriptyline (Allegron) and trazodone (Molipaxin)
- MAOIs – Monoamine oxidase inhibitors, including drugs such as moclobemide (Manerix) and phenelzine (Nardil)
Those we interviewed had mainly used TCAs and MAOIs before the 1990s, or if recommended by their doctor for their particular circumstances. People we spoke to seemed more concerned about the side effects of these drugs, compared to those describing the newer anti-depressants (see ‘Newer Anti-depressant medication: SSRIs and SNRIs’). With tricyclics (TCAs), people talked about side effects such as constipation, drowsiness, dry mouth, blurred vision, tremor, and weight gain. MAOIs could make people feel sluggish and drowsy, gain weight, and there was a risk of fainting when standing up due to low blood pressure. Because of the risk of a sudden increase in blood pressure called ‘hypertensive crisis’, people on MAOIs had to follow a strict tyramine-free diet, excluding such diverse foods as broad bean pods, cheese and marmite. Thus, MAOIs are prescribed by psychiatrists and people have to be supervised when they start to take them.
For more information see our antidepressants section.
Episodes of depression can occur alone (‘unipolar depression’) or with episodes of related mood swings (‘bipolar disorder’). This is an important distinction to make, as it may affect whether or not antidepressants are suitable, and whether other medication might be better. Antidepressants are usually used to treat unipolar depression, but, in bipolar disorder different medications may be used, such as mood stabilisers (e.g. lithium or valproate) and/or other medicines such as quetiapine and mirtazapine.
Lithium is used routinely in bipolar disorder as it has a therapeutic effect on both depression and manic episodes, and is also used as an ‘add-on’ medication in treating depression alone. A number of people took lithium, a drug which was first used to control bipoplar disorder (previously known as manic depression). People with bipolar are thought to have a chemical disturbance in the brain which causes alternate periods of very high and very low mood, over periods of weeks or months. Sometimes these mood swings go in only one direction – either high or low – and this is called ‘unipolar disorder’. Lithium can help some people who experience serious downward swings into depression, whether or not these lows are followed by highs.
Many people said that lithium helped them to steady their moods, and avoid extreme highs and lows. However, people on lithium had to have their blood monitored regularly to avoid toxic blood levels or under treatment. There were also side effects with lithium that people did not like. Common side effects included increased urination, increased thirst, metallic taste in the mouth, mild nausea, weight change, hair loss and trembling hands.
One man felt that lithium took away some of the enjoyment of life, as well as his creativity and ‘about 10 IQ points.’ He wanted to be in control of his treatment, and so he negotiated with his doctor to come off lithium.
Unfortunately, some found that reducing their lithium led to depression again. Some people who needed lithium were tempted to come off it when they felt well, not realising how it was preventing mania and depression. A few were angry that their doctors were not aware of less common problems with lithium such as hair loss (due to low thyroid function).
Although friends of hers did well on lithium, one woman was adamant that lithium made her more paranoid, and also suicidal and violent. After much effort, she persuaded her doctor to change to another medication, and she then improved substantially.
Was well informed about lithium side effects, and was willing to take lithium to avoid depression…
Says he did not like taking lithium because it stopped him doing things he enjoyed, and so he…
He tends to become depressed when he tries to come off lithium, although his last depression wasn…
He lost his faith in psychiatrists when his hair fell out. His psychiatrist initially said it was…
Though her friends did well on lithium, she became suicidal and very paranoid before she stopped…
For more information on lithium see MIND’s booklet ‘Making sense of lithium and other mood stabilisers’.
Electroconvulsive therapy (ECT)
People who had electroconvulsive therapy (ECT) were so severely depressed they were often in hospital at the time (although people do, for example, attend as outpatients for ‘maintenance’ treatments from time to time). Being severely depressed, it was difficult for people to decide whether or not ECT was the right treatment. One man said, ‘I didn’t know what ECT meant’ when he had begun a series of 20 sessions of ECT. Our website on ECT includes many more experiences of and information on ECT.
One woman insisted that ECT had resulted in her extraordinary recovery. Others had more mixed experiences, felt only slight improvements, or were unsure if there was any benefit. Because many were also taking medication for depression, some found it difficult to know if ECT had helped them. The main problems reported were memory loss (temporary and more permanent), severe headaches, tearfulness, and feeling confused and frightened by the whole experience, including anaesthetic and waking up disorientated.
Several people reported memory loss after ECT, e.g. they forgot names of things, forgot whole holidays they had been on. A few people had a particular dislike of ECT, and some were traumatised by the whole experience. Some people associated the look and smell of the ECT theatre with their negative and frightening experiences. One woman avoided further ECT treatment by pretending she was better. Another woman tried to find the humour in a frightening experience.
While she was unable to give consent to ECT (Electroconvulsive Therapy) in hospital, her recovery…
He ‘swallowed his tongue during ECT (Electroconvulsive Therapy) and had to try to alert the…
Did not like ECT (Electroconvulsive Therapy), felt frightened and confused, and when she tried to…
Some felt that they side effects of ECT were more substantial than they were initially led to believe. Some reported the loss of long term memories, and doctors were not open about the possibility of memory loss.
After ECT (Electroconvulsive Therapy), she has no memory of specific time periods, and her…
People said that their ECT experience was better if staff were friendly and helped to put them at ease throughout the procedure. For more information on electroconvulsive therapy see our website on ‘Electroconvulsive thereapy’ or the MIND’s website.
For more information on advance directives and the Mental Capacity Act see Mind’s website.
Anti-anxiety and sleeping tablets
Anxiety and panic were very common among the people we talked to. Two common treatments for anxiety were benzodiazepines (e.g. diazepam, lorazepam, chlordiazepoxide), and beta-blockers (e.g. Inderal (propanolol)). Some benzodiazepines (e.g. temazepam) were also used to help people sleep. These drugs helped many people to cope with anxiety and sleep better. But few people had become addicted to benzodiazepines and had trouble withdrawing, and such people need support from their GPs to withdraw very gradually.
For more information see MIND’s website, Sleeping pills and minor tranquillisers.
A number of other medications are now being used to treat depression or unipolar depression and some are still classed as antidepressants but some were developed for other conditions. We have not yet interviewed people about most of these medications.
Agomelatine (Valdoxan) is a type of antidepressant that works by helping to restore the balance of circadian rhythms (the ‘body clock’ which tells us when to sleep and regulates many other physical, mental and behavioural processes). It is licensed in the UK but has not yet been approved by NICE.
Quetiapine (Seroquel) is an antipsychotic medication that has been approved as add on treatment for those with major depression. It is also use to ease symptoms of schizophrenia, bipolar disorder and other mental health problems. Quetiapine works on the balance of chemical substances in the brain and is used to help keep moods within normal limits.
Mirtazapine (Zispin SolTab) is a presynaptic alpha 2 adrenoreceptor antagonist unrelated to SSRIs or SNRIs. It is thought that this medicine acts on receptors in the brain, increasing the amounts of the chemical messengers noradrenaline and serotonin and can improve mood. It often causes sedation during initial treatment. It is more usually prescribed to people with serious depressive symptoms but is sometimes given to help with insomnia. The following experiences of this medication are from our website on ‘Experiences of antidepressants’.
Lucy Y was functioning’ on fluoxetine but mirtazapine made…
Sonia was prescribed mirtazapine to help her sleep, because…
Thomas took mirtazapine but the sedative effects disrupted his…
Collette changed from mirtazapine to duloxetine, which…
Viibryd (Vilazodone) has similar functions to an SSRI in that it inhibits reuptake of serotonin, but it also affects the 5-HT1A receptor as a partial agonist and is seen as a unique type of antidepressant. This medication is particular popular in the USA as it is not associated with significant weight gain or sexual dysfunction but it had not yet been approved by NICE and is only prescribed to registered users.
Oxford University’s Department of Psychiatry has carried out some research in the use of ketamine for severe depression. It has shown that for people with severe depression (including those with depression as part of bipolar disorder) that have not responded to other treatments the use of ketamine may be beneficial. This type of depression only affects a small number of people with the condition, and the research into using ketamine is still at a very early stage.