ADHD and Tricyclics

Once considered a primary agent in the treatment of depression, tricyclics antidepressants (TCAs) have been found to reduce the symptoms of hyperactivity and impulsivity in individuals with ADHD. However, use of TCAs can be risky and should only be used under the strict supervision of a qualified physician.

Types Imipramine and nortriptline are the two type of TCAs most commonly prescribed for ADHD. Imipramine is distributed under the brand name Tofranil whereas nortriptline is distributed under under the brand names Pamelor and Aventil. Desipramine—a third type of TCA distributed under the brand name Norpramin—should only be used as a last resort as its been linked to sudden death syndrome in children.¹

TCAs inhibit the reuptake of norepinephrine and serotonin in the brain.²TCAs can be a good choice for ADHDers with an associated disorder such as anxiety, depression, oppositional disorders and motor tics. TCAs can also be a convenient option for children who wet the bed.³

Research shows that whereas TCAs are effective at alleviating the symptoms of hyperactivity and impulsivity, they are less effective than stimulants at reducing the symptom of inattentiveness.³ TCAs have also been known to decreases aggression and increase an individual’s ability to be social.

Unlike stimulants, TCAs can several weeks to kick in and are rarely as robust. The starting dose for TCAs is 25 mg per day with a gradual increase of up to 5 mg per kilo of patient weight daily.⁴ However some practitioners have found then effective in dosages as low as 10 mg per day.⁵ TCAs can be a good choice for ADHDers with an associated disorder such as anxiety, depression, oppositional disorders and motor tics. TCAs can also be a convenient option for children who wet the bed.

Medical practitioners and psychiatrists

TCAs have also been linked to sudden death syndrome in children. For this reason, many clinicians put them at the bottom of the list of ADHD medications for children. TCAs can also be risky for substance abusers. Before starting TCA treatment for children, doctors recommend getting a baseline EKG in addition to monitoring side effects.

Side effects

The side effect associated with Tricyclic antidepressants are usually mild. These may include:

• Dry mouth
• Drowsiness
• Constipation
• Weight gain
• Difficulty with urination
• Blood pressure changes
• Risk of severe mood and behavior changes, including suicidal thoughts (Young adults may be at a higher risk for this side effect.)

To reduce the risk of side effects, your doctor will prescribe a low starting dose and slowly increase the amount. Tricyclics are generally well-tolerated especially in low doses. The doses needed to induce pain relief are typically lower than the doses recommended for treating depression

All of the Tricyclics have the same side effects, but in varying degrees. To fully understand these potential side effects, they are grouped as follows:

• Anticholinergic- These side effects range from unpleasant (dry mouth, dry skin, blurred vision, and constipation) to serious (paralytic ileus, cessation of the movement of the intestine, which can lead to intestinal rupture and death; and urinary retention, inability to urinate, which in serious cases can lead to rupture of the bladder).

• Adrenergic- Side effects can include sweating, sexual dysfunction, and orthostatic hypotension-- sudden drop in blood pressure upon rising and a sensation of lightheadedness. This condition can lead to a fall and, in turn, to fractures, which can have serious medical consequences, particularly in the elderly.

• Antihistaminic- Side effects include sedation and weight gain.

• Miscellaneous- Other side effects include lowered seizure threshold, cardiac arrhythmia, hepatitis, rashes, sweating, anxiety, and elevated heart rate.

1. H. Russell Searight, Ph.D., John M. Burke, Pharm D., and Fred Rottnek, M.D. “Adult ADHD: Evaluation and Treatment in Family Medicine,” American Family Physician, November 1, 2001.
2. Stephen W. Garber, Ph.D., Marianne Daniels Garber Ph.D., and Robyn Freedman Spizman, Beyond Ritalin (New York: Villard Books, 1996): 258.
3. “Medication Management for Adults with ADHD,” Attention Deficit Disorder Resources, www.help4adhd.org, http://www.addresources.org/articleadhdmedication_chadd.php
4. Thomas E. Brown, Ph.D., Attention Deficit Disorder: The Unfocused Mind in Children and Adults, (New Haven and London: Yale University Press, 2005): 267.
5. Stephen W. Garber, Ph.D., Marianne Daniels Garber Ph.D., and Robyn Freedman Spizman, Beyond Ritalin (New York: Villard Books, 1996): 257.
6. Thomas E. Brown, Ph.D., Attention Deficit Disorder: The Unfocused Mind in Children and Adults, (New Haven and London: Yale University Press, 2005): 267.