using TCAs

[randomdoc1]

I have to admit, I have not had terribly many experiences with TCAs in more medically complicated cases. Every once in a while I run into a case of someone who has treatment resistant depressive sx and issues with sleeping, failure of multiple medications and I have considered TCAs. I know other options are the newer sleep aids and antidepressants. But I was curious to see how other people are practicing. What kinds of medical comorbidities make you very hesitant to consider a TCA, which ones are more yellow light for you and you monitor with EKGs, and what types of cases (i.e. patient profiles) do you consider very low risk for TCAs? I'm generally comfortable with people who are medically not very complicated and have enjoyed how it helps some people with their sleep and pain. But what about the more medically complicated cases with multiple failed antidepressant trials?

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[thoffen]

Mechanistically, TCAs are serotonin and norepinephrine reuptake inhibitors. They are no magic bullet for treatment failure, and should be considered alongside augmenting strategies and other treatments (especially ECT which is often the magic bullet you are looking for). That said, some TCAs have significantly more NE reuptake inhibition than SNRIs so have potential clinical utility that is different. I do not believe that chronic insomnia should routinely be thought of as a medication target. If a TCA benefits sleep as a secondary effect, it will (biologically anyway) only be on a short-term basis. To me, this does not justify the choice of a TCA with higher antihistamine and anticholinergic activity. I generally think nortriptyline (least anticholinergic), desipramine (most noradrenergic, low anticholinergic activity, but highest toxicity risk), and clomipramine (most serotonergic/OCD indication) as worthy of having in your arsenal. Low dose doxepin is OK as a sleep treatment esp. given the FDA indication, but again I am very cautious in setting the expectation that a medication is going to treat chronic sleep problems.

 

[Shikima]

Mechanistically, TCAs are serotonin and norepinephrine reuptake inhibitors. They are no magic bullet for treatment failure, and should be considered alongside augmenting strategies and other treatments (especially ECT which is often the magic bullet you are looking for). That said, some TCAs have significantly more NE reuptake inhibition than SNRIs so have potential clinical utility that is different. I do not believe that chronic insomnia should routinely be thought of as a medication target. If a TCA benefits sleep as a secondary effect, it will (biologically anyway) only be on a short-term basis. To me, this does not justify the choice of a TCA with higher antihistamine and anticholinergic activity. I generally think nortriptyline (least anticholinergic), desipramine (most noradrenergic, low anticholinergic activity, but highest toxicity risk), and clomipramine (most serotonergic/OCD indication) as worthy of having in your arsenal. Low dose doxepin is OK as a sleep treatment esp. given the FDA indication, but again I am very cautious in setting the expectation that a medication is going to treat chronic sleep problems.

Enter CBT-I which is not widely presented as a treatment option.

 

[thoffen]

Enter CBT-I which is not widely presented as a treatment option.

Indeed. Nor is it widely available, but there are at least on-line options.

 

[Shikima]

Indeed. Nor is it widely available, but there are at least on-line options.

As I was typing, a former president of the AASM walked in and asked him this same question. He agrees that it's not widely taught and used and believes, as I do, that this is a problem. Especially in the female population.

 

[WisNeuro]

Indeed. Nor is it widely available, but there are at least on-line options.

Even when it is widely available, few patients actually want it, at least in my setting. In my feedback sessions following recommendations, I'd say maybe 5-10% of patients I refer for CBT-I actually take the referral after a lengthy discussion of the benefits. Most prefer to stay on their z-drugs. People just don't want to put in the work.

 

[Jules A]

Even when it is widely available, few patients actually want it, at least in my setting. In my feedback sessions following recommendations, I'd say maybe 5-10% of patients I refer for CBT-I actually take the referral after a lengthy discussion of the benefits. Most prefer to stay on their z-drugs. People just don't want to put in the work.

It is unfortunate that some prescribers will bend to the path of least resistance and prescribe whatever the patient demands. What I have found is when quantified a patient's report of insomnia is often not as clinically significant as their initial report indicates especially in the cases of those who are not working. Refusing to prescribe without justification can be more time consuming but opens the dialogue for sleep hygiene education or challenging flawed logic and that is where they might eventually see true growth.

 

[WisNeuro]

It is unfortunate that some prescribers will bend to the path of least resistance and prescribe whatever the patient demands. What I have found is when quantified a patient's report of insomnia is often not as clinically significant as their initial report indicates especially in the cases of those who are not working. Refusing to prescribe without justification can be more time consuming but opens the dialogue for sleep hygiene education or challenging flawed logic and that is where they might eventually see true growth.

I wholeheartedly agree. Many providers across healthcare do a terrible job in assessing sleep hygiene. I'm amazed at what patients are unaware of in terms of poor sleep habits (e.g., alcohol/coffee/cigarettes immediately before sleep, staring at a tablet/computer before bed every night, tv in the bedroom, etc). Far too often the patient only needs very small changes in bedtime routine to experience significant improvements in sleep latency and maintenance of sleep. Many don't even need the full CBT-I, they just need someone to go through their sleep routine and/or environment and help them make some adjustments.

 

[randomdoc1]

This is of course after I have referred to CBT by the way. Vitamin CBT is something I highly recommend to many of my patients, and some DBT in some cases for that matter but that is another story. But like many have said, few patients want to put in the work. I'm just curious about TCAs (in general), that's all.

And yes, I have visited therapy repeatedly with a number of my patients. Even employed motivational interviewing in this.

 

[Shikima]

Perhaps this then brings up a serious discussion; at what point do we need to go back to the authoritarian relationship to dictate how treatment will be for them coming to see you?

The pendulum has swung so drastically over the past 20-30 years where we have adopted a non-confrontational and soft approach which is further enhanced by two formidable thoughts; 1) I have a pill for that and 2) satisfaction surveys.

 

[randomdoc1]

Perhaps this then brings up a serious discussion; at what point do we need to go back to the authoritarian relationship to dictate how treatment will be for them coming to see you?

The pendulum has swung so drastically over the past 20-30 years where we have adopted a non-confrontational and soft approach which is further enhanced by two formidable thoughts; 1) I have a pill for that and 2) satisfaction surveys.

We can certainly discuss this. Just for the record for everyone, I'm generally not soft in my approach but I do like to consider other options when they are potentially of benefit. For most of my patients I discuss that prior to coming to me they've already tried sleep aids x, y, z, etc. etc. and that it is unlikely more sleep aids will help. I do very much push therapy and hold back tacking on another med when I think they'd do much better with a multi pronged approach. My own personal stance in general is that I tell them they've basically tried many sleep aids (that this approach is obviously not working) and some are on enough CNS depressing meds to knock out a horse. I tell them of the literature that has demonstrated the efficacy of CBT or whatever else I recommended. I also tell them that I'm not going to add on another medication because it is unlikely to resolve their sleep issues and will likely contribute to adverse side effects such as risk of falls, other medication interactions, etc. I basically make an analogy to that of a bandaid, that we can address the underlying problem/causes, or just try to throw another pill at it. But like I said, I do see that as a separate discussion.

And yes, I agree with another post. Sometimes a patient will just say "I haven't been sleeping." But when I ask them the number of hours and for finer details about naps, number of arousals, etc., it averages out to an adequate amount of sleep (and energy based on what they do in their free time) for that matter.

 

[jettavr6]

Therapy should always be offered with medication. That said, I echo the sentiments of Randomdoc1 in that patients sometimes don't want it, or cannot afford it. The most common issue is that insurance makes it difficult to offer in that there might be a higher copay, out of pocket cost, etc. TCA's can be used for augmentation, and there are many good suggestions above. I have one patient who is taking Desipramine and it wasn't started by me. Regardless, it saved her life. Another patient had done very well on Clomipramine, but it soon went off formulary from his insurance. No other medication had worked. He had to move to another city for work, and could not afford the $400 a month out of pocket cost. His mother called me a few months later to inform me that he became very depressed and began using drugs - he had a heart attack and died. He had been in CBT and had even had ECT in the past - Clomipramine had kept him stable for years.

 

[smalltownpsych]

Explain the options including effective sleep hygiene. Any good physician should be able to help with this. CBT-I is not really that much more complex than that. Let the patient make the choice.

A funny story is my mom has complained about her insomnia for years and has taken all sorts of medications for it and right after I was learning about sleep hygiene my brother told her that he thought that if she woke up early and at the same time like the rest of us who work for a living, then she would probably not have such a problem. She told him he didn't know what the hell he was talking about. I wonder if her psychiatrist ever told her that a consistent sleep schedule was a key component of CBT-I or if my mom just told her she didn't know what the hell she was talking about either.

 

[Ceke2002]

Just personally through trial and error I've found that I tend to tolerate TCA's far better than most other types of Antidepressants, hence for me I consider them more of a first line treatment option when I do require some extra pharmacological assistance in managing recurrent depressive symptoms (most other times I rely on active participation in therapy and choose to forego medication). When it comes to TCA's being good for effective sleep management in the longer term though I consider them to be about as useful as t!ts on a bull.