Antidepressants - Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs): Nursing pharmacology

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ANTIDEPRESSANTS: TCAs, MAOIs
DRUG NAME	Tertiary TCAs: amitriptyline (Elavil), imipramine, clomipramine (Anafranil) Secondary TCAs: desipramine (Norpramin), nortriptyline (Pamelor)	isocarboxazid (Marplan) phenelzine (Nardil) tranylcypromine (Parnate) selegiline (Emsam, Zelapar)
CLASS	Tricyclic antidepressants (TCAs)	Monoamine oxidase inhibitors (MAOIs)
MECHANISM OF ACTION	Inhibition of serotonin and norepinephrine reuptake into nerve endings	Monoamine oxidase inhibition to prevent the breakdown of serotonin, norepinephrine, and dopamine
INDICATIONS	Major depressive disorder Phobic, panic, anxiety disorders Obsessive-compulsive disorder Neuropathic pain Migraine prevention	Major depressive disorder Parkinson disease
ROUTE(S) OF ADMINISTRATION	PO	PO Transdermal (selegiline)
SIDE EFFECTS	Sedation Orthostatic hypotension Atropine-like side effects Lower seizure threshold Serotonin syndrome Black box warning: suicidal thinking in children, adolescents, and young adults	Hypertensive crisis Serotonin syndrome Black box warning: suicidal thinking in children, adolescents, and young adults
CONTRAINDICATIONS AND CAUTIONS	Administration within 14 days of MAOIs	Pheochromocytoma Cerebrovascular diseases Severe hepatic / renal impairment Dietary: avoid tyramine-rich food or drinks foods containing phenylalanine caffeine

NURSING CONSIDERATIONS: ANTIDEPRESSANTS (TCAs, MAOIs)
CLASS	TCAs	MAOIs
ASSESSMENT AND MONITORING	All antidepressants Baseline assessment of depressive symptoms; continue during antidepressant therapy Monitor for suicidal thoughts, especially during the first few weeks
	TCA Mental status Baseline and periodic ECG	MAOI Mental status Baseline renal and hepatic Signs of hypertensive crisis
CLIENT EDUCATION	All antidepressants Therapeutic effects can take 1–3 weeks Take medication exactly as prescribed Report any changes in symptoms or suicidal thoughts to health care provider
	TCA Make position changes slowly to manage orthostatic hypotension Manage anticholinergic side effects with sugar free gum, or candies; sips of water; fiber, fluids, physical activity; before taking the medication Take medication in evening; avoid hazardous activities to manage sedative effects	MAOI Make position changes slowly to manage orthostatic hypotension Avoid tyramine-rich foods; also foods containing tryptophan, phenylalanine Seek medical attention for symptoms of hypertensive crisis

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Content Reviewers

Antonella Melani, MD,Lisa Miklush, PhD, RNC, CNS,Gabrielle Proper, RN, BScN, MN

Contributors

Jung Hee Lee, MScBMC,Filip Vasiljević, MD,Katherine May, BSN, RN,Marisa Pedron

Antidepressants are medications primarily used to treat major depressive disorder, which is a condition associated with a persistent feeling of sadness and loss of interest in everyday activities.

Even though the exact cause of major depressive disorder is still unknown, there's some evidence that suggests that it’s related to low levels of neurotransmitters called monoamines, which include serotonin, norepinephrine, and dopamine.

In this video, we’re going to cover two of the main classes of antidepressants: tricyclic antidepressants and monoamine oxidase inhibitors.

First, let’s focus on tricyclic antidepressants or TCAs for short, which can be further subdivided into tertiary or non-selective TCAs, like amitriptyline, imipramine, and clomipramine; and secondary or selective TCAs, such as desipramine and nortriptyline.

Now, tricyclic antidepressants are taken orally, and once absorbed into the bloodstream, they travel to the brain. Here, TCAs inhibit the reuptake of serotonin and norepinephrine.

Sources

"Pharmacology: A Patient-Centered Nursing Process Approach (8e)" Elsevier Health Sciences (2014)

"Mosby's 2021 Nursing Drug Reference (34e)" Mosby (2021)

"Saunders Comprehensive Review for the NCLEX-RN® Examination (7e)" Saunders (2016)

"Focus on Nursing Pharmacology" LWW (2019)

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Antidepressants - Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs): Nursing pharmacology

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