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Depression
25 min read
Written by Klarity Editorial Team
Published: Dec 6, 2022
Medically Reviewed by Dr. Zoe Russell
Living with depression is draining—especially when your depression symptoms are resistant to treatment. When you have treatment-resistant depression, mental health providers often turn to less common antidepressants to try to relieve symptoms.
Silenor and Pamelor are two tricyclic antidepressant medications that can be prescribed when first-line depression medications fail to effectively reduce depression symptoms. We’ll be exploring these two tricyclic antidepressants in this article.
We’ll cover—
Depression—especially treatment-resistant depression—makes getting treatment feel like it takes an infinite amount of energy. Klarity makes online depression treatment easy and hassle-free. When you book on Klarity, you can meet virtually with a board-certified mental health provider who can diagnose and prescribe in 48 hours or less.
How do you get started? It’s easy—schedule an appointment, and we’ll connect you with a licensed care provider in your state who can help treat your depression symptoms.
This article discusses suicide, suicidal ideation, and self-harm. If you or someone you know is experiencing suicidal thoughts or is in crisis, contact the Suicide Prevention Lifeline immediately at 800-273-8255.
Pamelor | Doxepin | |
Drug Class | Tricyclic antidepressant | Tricyclic antidepressant |
Brand / Generic Status | Brand name for nortriptyline | Generic (Brand name: Silenor) |
Form(s) of the Drug | • Immediate-release capsules • Clear, cherry-flavored liquid suspension | • Immediate-release capsules • Immediate-release tablets • Clear, blueberry-mint flavored liquid suspension • Topical cream (for itching) |
Standard Dosage | Immediate-release capsules: • 10mg • 25mg • 50mg • 75mg Liquid suspension: • 10mg per dose | Immediate-release capsule: • 10mg • 25mg • 50mg • 75mg • 100mg • 150mg Immediate-release tablets: • 3mg • 6mg Liquid suspension: • 10mg per dose Topical cream: • 5% formula |
Conditions Treated | FDA-approved uses: • Major depressive disorder Off-label uses: • Diabetic neuropathy • Migraines • Postherpetic neuralgia or post-shingles skin pain • Neurogenic cough • Chronic pain • Persistent myofascial pain • Trigeminal neuralgia or painful shock sensations on the face | FDA-approved uses: • Major depressive disorder • Anxiety disorder • OCD Off-label uses: • Itchiness due to atopic dermatitis, pruritus, or lichen simplex chronicus • Topical neuropathic pain |
Cost | Brand name (Pamelor): • $1250 for a 30-day supply (no insurance) • $10 for a 30-day supply (with insurance) Generic form (nortriptyline): • $13 for a 30-day supply | Brand name (Silenor): • $32 to $525 for a 30-day supply Generic form (doxepin) • $36 to $90 for a 30-day supply • $8 for a 30-day supply with coupons/discounts |
Side-Effects | Common side effects: • Blurred vision • Impaired coordination • Physical weakness • Constipation • Nausea and vomiting • Sensitivity to sunlight • Xerostomia or dry mouth • Dizziness • Excessive sweating • Breast gland tissue growth • Insomnia • Drowsiness • Increased need to urinate • Abnormal sensations • Agitation • Urinary retention • Tremoring • Disorientation • Anxiety • Changes in blood sugar levels • Confusion • Galactorrhea or nipple discharge • Skin rash • Itchy skin • Restlessness | Common side effects: • Agitation, confusion • Black, tarry stools, bleeding gums, blood in urine or stool • Blurred vision • A sensation of burning, itching, or “pins and needles” on the skin • Chest pain or tightness, fast or irregular heartbeat • Chills, cold sweats • Urinary retention • Dizziness upon standing, loss of consciousness • Headache • Hearing loss • Muscle spasms, stiffness, twitching • Seizures |
Warnings For Use | Drug interactions: • Arbutamine • Blood thinning medications like Warfarin • Disulfiram • Thyroid Supplements • Anticholinergic drugs • Clonidine • Guanabenz • MAOIs | Drug interactions: • Thyroid supplements • Anticholinergic drugs • Some blood pressure medications: clonidine • MAO inhibitors: isocarboxazid, linezolid, metaxalone, methylene blue • SSRIs • St. John's Wort • Cimetidine • Terbinafine • Drugs to treat irregular heart rate |
Pamelor and Silenor are both tricyclic antidepressants, which are the oldest antidepressant drug class developed to treat major depressive disorder (MDD). While tricyclics aren’t right for everyone, they can be useful alternatives when other forms of treatment no longer work or aren’t an option.
Tricyclics refer to a class of medications that are used to treat depression, anxiety, and other mental health disorders. They are called tricyclics because their chemical structure contains three rings of atoms.
Tricyclics work by affecting the levels of certain neurotransmitters in the brain, such as serotonin and norepinephrine. These neurotransmitters play a key role in regulating mood, emotions, and other mental processes.
Medications like Silenor and Pamelor block the reuptake of serotonin and norepinephrine by the neurons in the brain, which means that these neurotransmitters stay in the synapse longer and can have a greater effect on mood and other mental processes.
By increasing the levels of these neurotransmitters, tricyclics can help alleviate symptoms of depression, anxiety, and other mental health disorders.
However, tricyclics can also have a range of side effects, including drowsiness, dry mouth, weight gain, and constipation, among others. As such, they are typically only used as a second-line treatment option after other medications have been tried and found to be ineffective.
While Pamelor and Silenor are both used to treat major depressive disorder, they’re prescribed in different doses and can have unique side effects. Additionally, each antidepressant can be used off-label to treat conditions outside of MDD.
If a medication is used for something other than its FDA-approved use, it’s considered an off-label treatment. If, for example, a medication is FDA-approved to treat cardiovascular conditions but can help alleviate anxiety, healthcare providers may use it to treat anxiety symptoms in an off-label capacity.
Pamelor (Nortriptyline) is primarily prescribed to treat MDD. That said, it can also be used off-label to treat several issues outside of depression.
Silenor is most commonly used to treat depression and anxiety. However, like Pamelor, it also has been prescribed off-label to treat other issues.
Silenor comes in different forms and doses, and how you’ll take it depends on your current symptoms, health history, and the advice of your mental healthcare provider.
Silenor is typically prescribed as a tablet, capsule, or liquid. While everyone’s dosage on this antidepressant varies, you can expect to start with 10 to 75 mg daily. Your healthcare provider may increase that dose to 150 mg daily, depending on your symptoms and how you respond to the initial dosing recommendation.
Doxepin has some possible side effects you should be aware of before taking this antidepressant.
Common side effects include:
Some of these side effects may go away with time, but you should alert your healthcare provider if these possible side effects do not. If you experience any of the following serious side effects while taking this treatment, contact your provider immediately or seek emergency medical care.
Silenor is metabolized by the liver, primarily through the enzyme system known as CYP450. Therefore, a treatment that inhibits or induces this system can affect the metabolism and clearance of Silenor, potentially leading to drug interactions.
Some drugs that may interact with Silenor include:
The price of Silenor varies depending on the dose you’re prescribed and which pharmacy you use. You could pay anywhere from $16.99 to $49.47 a month. If you’re looking for a more affordable alternative, speak with your care provider about using the Silenor.
Pamelor doesn’t come in as many forms as Silenor, and it has its own unique side effects. Whether you receive higher doses or low doses depends on what your healthcare provider recommends, which will vary from person to person.
Pamelor is a capsule taken orally in doses ranging from low doses to high from 25 mg to 150 mg per day. Your healthcare provider will likely start you on a low dose to see how you respond to the medication, increasing it as needed to treat your depression symptoms.
Common side effects of Pamelor may dissipate over time as your body gets used to the medication. Those side effects include the following.
If you experience persistent unwanted side effects, you must talk with your mental health provider about your options before abruptly stopping Pamelor.
Like Silenor, Pamelor (nortriptyline) is also metabolized by the liver through the same enzyme system—CYP450. Therefore, medications that affect this system can affect how Pamelor is metabolized in the body.
Some drugs that may interact with Pamelor include:
Pamelor can be quite costly if you’re paying without insurance, with prices starting at $1,251 for 30 capsules of 10 mg. However, the generic version is much more affordable at $21 for 30 capsules at 25 mg. Consult your healthcare provider about your options so that you can get the best available price.
Yes, both Pamelor and Silenor are only available with a prescription. Selling tricyclic antidepressants without requiring a prescription is illegal and can put your health at risk, as there’s no way to know if the treatment includes harmful substances. Using a trusted pharmacy to fill your prescriptions is your best bet.
Tricyclic antidepressants can result in some serious side effects, pregnancy risks, and the possibility of increased bleeding. If you experience any of these side effects, contact emergency medical services and alert your care provider.
Serotonin Syndrome is a serious drug reaction that produces too much serotonin in the system. This reaction usually occurs when you’re taking multiple medications with serotonin or begin taking a new one that impacts serotonin levels. Signs and symptoms include:
If you experience any of those symptoms, contact your care provider immediately, as this syndrome can be fatal if left untreated.
While using tricyclic antidepressants during pregnancy isn’t necessarily unsafe, it can result in preterm delivery, low birth weight, respiratory distress, and neonatal convulsions. If you become pregnant, speak with your healthcare provider about your options for treating your depression symptoms.
Because tricyclic antidepressants influence serotonin levels, there’s an increased risk of bleeding that only occurs when the patient is already on a blood thinner like Warfarin. Platelets in your blood release serotonin to help heal wounds and form blood vessels. When taken with other medications that impact serotonin levels, you could have abnormal bleeding. Talk with your healthcare provider immediately if bleeding events occur.
Silenor is a tricyclic antidepressant most often prescribed to treat major depressive disorder (MDD). It can also be used off-label to treat neuropathic pain, anxiety, and insomnia.
Pamelor is a tricyclic antidepressant used for major depressive disorder. Its off-label uses include treating chronic pain to diabetic neuropathy, myofascial pain, orofacial pain, postherpetic neuralgia, headaches, and migraines.
While Silenor and Pamelor are both tricyclic antidepressants, they are not the same drug. They each have their own side effects and are prescribed in different doses depending on your symptoms.
Silenor is approved to treat anxiety, impacting your central nervous system to increase chemicals in the brain that help you relax. Pamelor enables you to feel better but may not alleviate anxiety symptoms. Which medication is best for you and your symptoms will depend on your health history and the advice of your mental health provider.
Both Silenor and Pamelor can treat symptoms of depression. That said, both have different drug interactions and side effects. Silenor has been used for over 40 years to treat depression, whereas Pamelor is a newer medication. Which one is best for you will depend on your current symptoms and the recommendation of your care provider.
Both antidepressants can cause drowsiness, and your healthcare provider may recommend taking your initial doses before bed until you understand how your body reacts to the medication. Once you’ve established that it’s safe, your healthcare provider may give you the green light to take your dose at a different time during the day.
Drinking alcohol on Silenor or Pamelor can reduce the effects of the medications and increase possible negative side effects. Consult your care provider before mixing alcohol with tricyclic antidepressants.
Because both medications can make you drowsy, you should not operate heavy machinery or drive until you know how these medications will affect you. You should always take your medicines as directed by your care provider, who will likely recommend taking your first dose before bed.
At Klarity, we know that trying to find a provider in your area, requesting time off from work, and commuting long distances for appointments can make accessing care much more difficult—especially when you are dealing with treatment-resistant depression.
Klarity makes online mental health treatment fast and hassle-free. When you book on our platform, we’ll connect you virtually with a board-certified mental health provider who can diagnose and prescribe medication online.
Ready to get better faster? Find a provider and meet with them in two days or less!
Sources:
“Doxepin (Depression, Anxiety)” MedlinePlus
https://medlineplus.gov/druginfo/meds/a682390.html
Mayo Clinic Staff. “Tricyclic antidepressants and tetracyclic antidepressants” Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20046983
John P. Cunha. “Pamelor” RxList
https://www.rxlist.com/pamelor-drug.htm
Gagindip Merwar; Jonathan R. Gibbons; Seyed Alireza Hosseini; Abdolreza Saadabadi. “Nortriptyline” National LIbrary of Medicine
https://www.ncbi.nlm.nih.gov/books/NBK482214/
Joanne Schneider, DNP, RN, CNP; Mary Patterson, CNP; and Xavier F. Jimenez, MD, MA. “Beyond Depression: Other Uses for Tricyclic Antidepressants” Cleveland Clinic
“Doxepin” Drugbank.com
https://go.drugbank.com/drugs/DB01142
IBM Micromedex. “Doxepin (Oral Route) Side Effects” Mayo Clinic
https://www.mayoclinic.org/drugs-supplements/doxepin-oral-route/side-effects/drg-20072083?p=1
David N. Neubauer. “Pharmacotherapeutic Approach to Insomnia in Adults” ScienceDirect
https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/doxepin
IBM Micromedex. “Doxepin (Oral Route) Proper Use” Mayo Clinic
https://www.mayoclinic.org/drugs-supplements/doxepin-oral-route/proper-use/drg-20072083
Femi Aremu. “Doxepin, Oral Capsule” Healthline
https://www.healthline.com/health/drugs/doxepin-oral-capsule#side-effects
“Doxepin Interactions” Drugs.com
https://www.drugs.com/drug-interactions/doxepin.html
“Doxepin” GoodRx
https://www.goodrx.com/doxepin
“Doxepin Prices, Coupons and Patient Assistance Programs” Drugs.com
https://www.drugs.com/price-guide/doxepin
“Pamelor Dosage” Drugs.com
https://www.drugs.com/dosage/pamelor.html
John P. Cunha. “Pamelor Side Effects Center” RxList
https://www.rxlist.com/pamelor-side-effects-drug-center.htm
“Pamelor Interactions” Drugs.com
https://www.drugs.com/drug-interactions/nortriptyline,pamelor.html
“Pamelor Prices, Coupons and Patient Assistance Programs” Drugs.com
https://www.drugs.com/price-guide/pamelor
“Nortriptyline Prices, Coupons and Patient Assistance Programs” Drugs.com
https://www.drugs.com/price-guide/nortriptyline
Mayo Clinic Staff. “Serotonin Syndrome” Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/serotonin-syndrome/symptoms-causes/syc-20354758
Beena N. Patel, AND Janalynn Beste, and Jean C. Blackwell. “ Antidepressant Use During Pregnancy” American Family Physician
“Serotonin” Cleveland Clinic
https://my.clevelandclinic.org/health/articles/22572-serotonin
“Compare Doxepin vs. Pamelor” Iodine.com
https://www.iodine.com/compare/doxepin-vs-pamelor
“Cautions – Antidepressants” NHS
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