Tricyclic Antidepressants, or TCAs

Tricyclic Antidepressants, or TCA:
Cyclic antidepressants are named tri (3), or tetra (4), depending on the # of rings in their chemical makeup.
Maprotiline is a Tetracyclic antidepressant because it has 4 rings.

All of the medications listed below are Tricyclic antidepressants:

  • Amitriptyline
    • Initial dose:
      25 to 100mg per day in 3 to 4 divided doses or 50 to 100 mg at bedtime.
    • Maintenance dose:
      25 to 150 mg per day in single or 3 to 4 divided doses.
Amitriptyline

Amitriptyline

  • Amoxapine
    • Initial dose:
      50mg 2, or 3x daily.
      Depending on tolerance, the dosage can be increased to 100mg 2, or 3x daily by the end of the 1st week. When an effective dosage is established, the drug may be given in a single dose (nor more than 300mg) at bedtime.
    • Maintenance: 200-300mg/daily. 
Amoxapine

Amoxapine

  • Desipramine (Norpramin)
    • Initial dose: 75mg/day orally given as a single dose or in divided doses.
    • Maintenance dose: 100-200mg/day.
Desipramine

Desipramine

  • Doxepin
    • For Mild Depression:
      Initial dose: 25mg/day in 1 to 3 divided doses.
      Maintenance dose: 25-50mg/day in 1 to 3 divided doses.
    • For Moderate Depression:
      Initial dose: 75mg/day in 1 to 3 divided doses.
      Maintenance dose: 75-150mg/day in 1 to 3 divided doses.
  • For Severe Depression:
    Initial dose: 150mg/day in 1 to 3 divided doses.
    Maintenance dose: 150-300mg/day in 1 to 3 divided doses.

    Doxepin carton

    Doxepin carton

  • Imipramine (Tofranil)
    • Hospitalized Patients:
      Initial dose: 100mg/day given in 3 to 4 divided doses.
      Maximum dose: 300mg/day.
    • Outpatients:
      Initial dose: 75mg/day given in 3 to 4 divided doses.
      Maximum dose: 300mg/day.
    • Intramuscular: Up to 100mg/day in divided doses.
tofranil-25mg

Tofranil 25mg

  • Nortriptyline (Pamelor)
    • 25-150 mg/day orally in divided doses or 1 dose.
Nortriptyline

Nortriptyline

  • Protriptyline (Vivactil)
    • 15 -40mg/day divided into 3 or 4 doses, up to 60mg/day, if necessary.
Protriptyline-hydrochloride

Protriptyline-hydrochloride

  • Trimipramine (Surmontil)
    • Outpatients:
      Initial: 75mg/day, orally in divided doses.
      Titration: May increase up to 150mg/day.
      Usual range: 50-150mg/day.
    • Hospitalized patients: 100mg/day, orally in divided doses.
      Titration: May increase gradually over a few days to 200mg/day.
      If there is no improvement after 2 to 3 weeks, the dose may be increased to 250 to 300 mg per day.
      Maximum Dose: 300 mg per day.
Trimipramine

Trimipramine

Common Side Effects:

  • Dry mouth
  • Blurred vision
  • Constipation
  • Urinary retention
  • Drowsiness
  • Increased appetite leading to weight gain
  • Drop in blood pressure when moving from sitting to standing, which can cause lightheadedness
  • Increased sweating

IMPORTANT: Pharmaceutical companies HAVE to list every side effect reported during clinical trails. So, just because a medication lists a certain side effect DOES NOT MEAN YOU will have it. In fact, most people experience very few side effects and with continued use (2 weeks and beyond), most of the initial side effects dissipate, or resolve completely. Additionally, the dosages listed above are FDA approved for treating Depression in an otherwise healthy Adult. For more specific information in treating your symptoms, consult your doctor. 

**Nearly all of the medications listed above have been replaced by newer antidepressants with less side effects. See my posts on SSRIs and SNRIs **

Serotonin and Norepinephrine Reuptake Inhibitors, or SNRIs

Serotonin and Norepinephrine Reuptake Inhibitors, or SNRIs:

  • Duloxetine (Cymbalta)
    • For Depression: Cymbalta should be administered a total dose of 40mg/day (20mg 2x daily) to 60 mg/day (given either 1x daily or 30mg 2x daily). There is no evidence that doses greater than 60mg/day give additional benefits.
    • 20 mg opaque green capsules imprinted with “Lilly 3235 20mg”
    • 30 mg opaque white and blue capsules imprinted with “Lilly 3240 30mg”
    • 60 mg opaque green and blue capsules imprinted with “Lilly 3270 60mg”
cymbalta

Cymbalta 60mg

  • Venlafaxine (Effexor XR)
    • Immediate release:
      Initial dose: 37.5 mg orally twice a day or 25 mg orally 3 times a day
      Maintenance dose: May increase in daily increments of up to 75 mg at intervals of no less than 4 days
      Maximum dose: (moderately depressed outpatients): 225 mg/day
      Maximum dose (severely depressed inpatients): 375 mg/day
      Daily dosage may be divided in 2 or 3 doses/day
      Extended release, or XR:
      Initial dose: 75 mg orally once daily
      Maintenance dose: May increase in daily increments of up to 75 mg at intervals of no less than 4 days
      Maximum dose (moderately depressed outpatients): 225 mg/day
      Maximum dose (severely depressed inpatients): 375 mg/day
    • EffexorXR 75 and 150mg

      EffexorXR 75 and 150mg

  • Desvenlafaxine (Pristiq)
    • 50 mg 1x daily, with or without food.

      pristiq

      Pristiq 50mg

Common Side Effects:

  • Nausea
  • Dry mouth
  • Dizziness
  • Excessive sweating

Other side effects may include:

  • Tiredness
  • Difficulty urinating
  • Agitation or anxiety
  • Constipation
  • Insomnia
  • Sexual problems, such as reduced sexual desire, difficulty reaching orgasm, or the inability to maintain an erection (erectile dysfunction)
  • Headache
  • Loss of appetite

IMPORTANT: Pharmaceutical companies HAVE to list every side effect reported during clinical trails. So, just because a medication lists a certain side effect does not mean YOU will get it. In fact, most people experience very few side effects and with continued use (2 weeks and beyond), most of the initial side effects dissipate, or resolve completely.

Statistics, logistics and ballistics

Most of the time, I hate stats. It’s one of my least favorite subjects. Frankly, I think most people would agree. But, it’s a necessary evil in this field. So, I put together a few points of logistical relevance so you don’t have to go ballistic on this stuff!

5 takeaway points for evaluating statistics and drug studies:

1-Even in a double-blind study, reported side effects can tip off the clinician as to whether the subject has received the placebo, or the actual treatment.
2-The placebo effect-is shown when a sugar pill is given to the control group and can lead to positive (and less likely negative) symptoms just simply by receiving something from a clinician. This speaks to the power of the mind.
3-Our mind can work against us, too, with the nocebo effect-setting someone up for possible negative side effects by telling them that “you may get all these side effects, or symptoms: lupus, scleroderma, blurred vision, dry mouth, and left foot paralysis.” It never fails that someone will report left foot paralysis!! As you may know there is not a single drug That’s the power of suggestion!
4-Here’s a great tip when deciding whether to read a study, or not. If your confidence interval is <1.0 it IS statistically significant!! If it includes 1.0, don’t read the study because it is NOT statistically relevant.
5-Risk ratio-is the point estimate used for cohort studies.

Q: What’s the difference between a psychologist, a psychiatrist and a medical psychologist?

Haha, there has to be a joke in there somewhere!!
But, for real, this is a common question I’m asked when I tell people about the psychopharmacology program.

A: The simple answer is:

“not very much” and “a whole lot” …read on.

A: The complicated answer is:

A psychologist has a minimum of the following:

  • BA in clinical psychology, sociology, or related field
  • MA in psychology (can be obtained interim)
  • Supervised by licensed clinician for 1500 pre-doc hours
  • Doctorate in psychology (Either PsyD, or PhD, EdD, etc.)
  • Sup. by licensed psychologist for 1500 post-doc hours
  • Successful passing of the National Exam
    • In the United States that is the Examination for Professional Practice in Psychology, or EPPP
  • Successful passing of the State Ethical Exam
    • In California it is the California Psychology Supplemental Examination, or CPSE
  • Accepted application and initial fee to State of licensure
    • California Board of Psychology, or CA BOP

source: 
Please also refer to my other post discussing the requirements that a licensed psychologist must meet prior to licensure.

A psychiatrist has a minimum of the following:

  • BA in psychology, or a related field
  • MD from medical school completion
  • Residency completion
  • The United States Medical Licensing Examination USMLE is a multi-part professional exam sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME)
  • Passing of the State medical board
  • Accepted application and initial fee to State of licensure

sources: 
-Cloud, J. (2010). Psychology vs. Psychiatry: What’s the Difference, and Which Is Better? Time.  
-http://www.usmle.org/ 

Okay, here is where it gets a bit confusing…

A Medical Psychologist can be a:

1-highly trained and licensed psychologist
WHO CAN PRESCRIBE PSYCHOTROPIC MEDICATIONS: 

OR

2-highly trained and licensed psychologist
WHO CANNOT PRESCRIBE ANY MEDICATIONS 

sources:
upon request.

CONCLUSION:
The lines between psychiatry and medical psychology are becoming blurred. Though, they are admittedly VERY different fields with different qualifications and degrees. It is this author’s belief that the blur happens from a variety of sources: depictions on television and other media outlets, misinformation, miseducation, interpretation and perception. But, the most important blur is occurring due to the nation-wide scarcity of prescribers, in general! You may have noticed the increasing amount of Nurse Practitioners, Physician’s Assistants and dun-dun-dun-dun-duuuuun… Medical Psychologists!

Some people prefer to call a psychologists who can prescribe a “prescribing psychologist” in Louisiana, New Mexico, Guam, Native American territories, and some state and Federal departments (currently the only places said professional can prescribe.) Makes sense, but in Louisiana, many entities, (including the ones who license folks) call a psychologist who can prescribe psychotropic medications a “medical psychologist” even using the suffix “MP.” ex-Jen Chandler, PsyD, MP

Other similar names have popped up over the years, including: psychopharmacologist, pharmacopsychologist, pharmacology psychologist, psychology pharmacologist, prescribing psychologist, RxP, and as discussed medical psychologist. In my opinion, the varying names for this practice may highlight the general disorganization of the field of psychology. Historically, we have not been our own best advocates…

Hope this clears up some misinformation, or confusion. Thanks for reading.

Sharing is caring,
Dr. Jen Chandler

I started this blog because…

I want to hold myself and other  colleagues accountable for learning and implementing the material we are learning in our Post-doc Master of Science in Clinical Psychopharmacology so that we will pass the Psychopharmacology Examination for Psychologists (AKA PEP) the first go-round.

Here is a brief introduction to what the heck all that means!

A Post-doc Master of Science in Clinical Psychopharmacology is a post-doctoral degree that can only be obtained when the following prerequisites have been met:

  • Licensed clinical psychologist
    • BA in clinical psychology, sociology, or related field
    • MA in psychology (can be obtained interim)
    • Supervised by licensed clinician for 1500 pre-doc hours
    • Doctorate in psychology (Either PsyD, or PhD)
    • Sup. by licensed psychologist for 1500 post-doc hours
    • Successful passing of the National Exam
      • In the United States that is the Examination for Professional Practice in Psychology, or EPPP
    • Successful passing of the State Ethical Exam
      • In California it is the California Psychology Supplemental Examination, or CPSE
    • Accepted application and initial fee to State of licensure
      • California Board of Psychology, or CA BOP
  • Preferred to be actively practicing as a psychologist
  • Time, dedication and money for the course work ahead
  • Passing of the Psychopharmacology Examination for Psychologists, the PEP
    • In Louisiana, it is required to become licensed as a psychologist and medical psychologist, and
    • Consult with a medical doctor, psychiatrist, or medical psychologist for 3 years

I hope this gives you a helpful introduction to the field of medical psychology, prescribing psychology, psychopharmacology, or otherwise known as pharmacopsychology — more on this next time!

Thanks for reading!
Sharing is caring,
Dr. Jen Chandler

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