Tricyclic Antidepressants

Also indexed as: Adapin®, Amitriptyline, Amoxapine, Asendin®, Clomipramine, Desipramine, Doxepin, Elavil®, Imipramine, Janimine®, Ludiomil®, Maprotiline, Norpramin®, Nortriptyline, Pamelor®, Pertofrane®, Protriptyline, Sinequan®, Surmontil®, Tofranil®, Trimipramine Maleate, Vivactil®

Combination drug: Triavil®, Etrafon®

Tricyclic antidepressants are used to treat people with depression and less commonly to treat other illnesses.

Summary of Interactions with Vitamins, Herbs, and Foods
(for details about the summarized interactions, read the full article)

Beneficial May be Beneficial: Depletion or interference—The medication may deplete or interfere with the absorption or function of the nutrient. Taking these nutrients may help replenish them.

CoQ10*
Beneficial May be Beneficial: Supportive interaction—Taking these supplements may support or otherwise help your medication work better.

L-tryptophan*

Niacinamide

SAMe

Vitamin B-Complex

Vitamin B1

Vitamin B12

Vitamin B2

Vitamin B3

Vitamin B5

Vitamin B6
Avoid Avoid: Reduced drug absorption/bioavailability—Avoid these supplements when taking this medication since the supplement may decrease the absorption and/or activity of the medication in the body.

Tea*
Avoid Avoid: Adverse interaction—Avoid these supplements when taking this medication because taking them together may cause undesirable or dangerous results.

St. John’s wort*
Side effect reduction/prevention

None known

An asterisk (*) next to an item in the summary indicates that the interaction is supported only by weak, fragmentary, and/or contradictory scientific evidence.

Interactions with Dietary Supplements

B vitamins
Giving 10 mg per day each of vitamins B1, B2, and B6 to elderly, depressed persons already on tricyclic antidepressants improved their depression and ability to think more than placebo did.1 The subjects in this study were institutionalized, so it is unclear if these results apply to persons living at home.

L-tryptophan and Vitamin B3
Combination of 6 grams per day L-tryptophan and 1,500 mg per day niacinamide (a form of vitamin B3) with imipramine has shown to be more effective than imipramine alone for people with bipolar disorder.2 These levels did not improve the effects of imipramine in people with depression. Lower amounts (4 grams per day of L-tryptophan and 1,000 mg per day of niacinamide) did show some tendency to enhance the effect of imipramine.

The importance of the amount of L-tryptophan was confirmed in other studies, suggesting that if too much L-tryptophan (6 grams per day) is used, it is not beneficial, while levels around 4 grams per day may make tricyclic antidepressants work better.3 4

Coenzyme Q10
A number of tricyclic antidepressants have been shown to inhibit enzymes that require coenzyme Q10 (CoQ10), a nutrient that is needed for normal heart function.5 It is therefore possible that CoQ10 deficiency may be a contributing factor to the cardiac side effects that sometimes occur with tricyclic antidepressants. Some practitioners advise patients taking tricyclic antidepressants to supplement with 30–100 mg of CoQ10 per day.

SAMe (S-adenosy-L-methionine)
SAMe may improve the clinical response to imipramine (Tofranil®). In a double-blind trial, depressive symptoms decreased earlier in the people who received SAMe injections (200 mg per day) in combination with imipramine than in those who received imipramine with placebo injections.6 Oral supplementation with SAMe has demonstrated antidepressant activity, independent of its combination with imipramine.7

Interactions with Herbs

St. John’s wort (Hypericum perforatum)
Preliminary research has suggested that St. John’s wort may reduce blood levels of the tricyclic antidepressant amitriptyline.8 This may have occurred because certain chemicals found in St. John’s wort activate liver enzymes that are involved in the elimination of some drugs.9 10 Until more is known, people taking tricyclic antidepressants should avoid St. John’s wort.

Tea (Camellia sinensis)
Brewed black tea has been reported to cause precipitation of amitriptyline and imipramine in a test tube.11 If this reaction occurred in the body, it could decrease absorption of these drugs. Until more is known, it makes sense to separate ingestion of tea and tricyclic antidepressants by at least two hours.

Interactions with Foods and Other Compounds

Alcohol
Tricyclic antidepressants can cause drowsiness and dizziness.12 Alcohol may intensify these actions, increasing the risk for accidental injury. People taking tricyclic antidepressants should avoid alcohol.

References

1. Bell IR, Edman JS, Morrow FD, et al. Brief communication: Vitamin B1, B2, and B6 augmentation of tricyclic antidepressant treatment in geriatric depression with cognitive dysfunction. J Am Coll Nutr 1992;11:159–63.

2. Chouinard G, Young SN, Annable L, Sourkes TL. Tryptophan-nicotinamide, imipramine and their combination in depression. Acta Psychiatr Scand 1979;59:395–414.

3. Walinder J, Skott A, Carlsson A, et al. Potentiation of the antidepressant action of clomipramine by tryptophan. Arch Gen Psychiatry 1976;33:1384–9.

4. Shaw DM, MacSweeney DA, Hewland R, Johnson AL. Tricyclic antidepressants and tryptophan in unipolar depression. Psychol Med 1975;5:276–8.

5. Kishi T, Makino K, Okamoto T, Kishi H, Folkers K. Inhibition of myocardial respiration by psychotherapeutic drugs and prevention by coenzymeQ. In Y Yamamura, K Folkers, Y Ito, eds. Biomedical and Clinical Aspects of Coenzyme Q, Vol. 2. Amsterdam: Elsevier/North-Holland Biomedical Press,1980:139–54.

6. Berlanga C, Ortega-Soto HA, Ontiveros M, Senties H. Efficacy of S-adenosyl-L-methionine in speeding the onset of action of imipramine. Psychiatry Res 1992;44:257–62.

7. Bressa GM. S-adenosyl-l-methionine (SAMe) as antidepressant: Meta-analysis of clinical studies. Acta Neurol Scand 1994;154(suppl):7–14.

8. Mai I, Schmider J, et al. Unpublished results, May, 1999. Reported in: Johne A, Brockmöller, Bauer S, et al. Pharmacokinetic interaction of digoxin with an herbal extract from St. John’s wort (Hypericum perforatum). Clin Pharmacol Ther 1999;66:338–45.

9. Nebel A, Schneider BJ, Baker RK, Kroll DJ. Potential metabolic interaction between St. John’s wortand theophylline [letter]. Ann Pharmacother 1999;33:502.

10. Mai I, Schmider J, et al. Unpublished results, May, 1999. Reported in: Johne A, Brockmöller, Bauer S, et al. Pharmacokinetic interaction of digoxin with an herbal extract from St. John’s wort (Hypericum perforatum). Clin Pharmacol Ther 1999;66:338–45.

11. Lasswell WL Jr, Weber SS, Wilkins JM. In vitro interaction of neuroleptics and tricyclic antidepressants with coffee, tea, and gallotannic acid. J Pharm Sci 1984;73:1056–8.

12. Threlkeld DS, ed. Central Nervous System Drugs, Antidepressants, Tricyclic Compounds. In Facts and Comparisons Drug Information. St. Louis, MO: Facts and Comparisons, Apr 1990, 262L–3.