Adverse effects of tricyclic antidepressants: focus on the elderly

By and large the tricyclic antidepressants are safe drugs. The adverse events associated with them often have more to do with the individual patient and any preexisting medical conditions or co-administered medications than with the particular tricyclic drug used. Only rarely will it prove unwise to treat major affective disorders with a tricyclic. The vast majority of the time the benefits of drug treatment will outweigh the risks. In milder cases or in patients whose depression is a symptom rather than a syndrome, the situation is more complex. Because a drug response becomes less certain and a placebo response more likely, one must very carefully balance the risks involved against the likely benefits of specific antidepressant treatment. While there are more frequent indications for the use of an antidepressant drug in a geriatric population than in a younger group, the risk of tricyclic antidepressant treatment undoubtedly increases as patients grow older. But even in the elderly, if a patient is healthy the drug is probably safe. Only when a patient has preexisting conduction disease, far advanced cardiovascular disease, or is on multiple other drugs are the risks of tricyclic treatment high. Here in particular, a careful understanding of the underlying pharmacology of the tricyclic drugs and their adverse reactions can produce a more rational and safe basis for treatment.