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.
Doxepin 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.
- How Tricyclics work
- What these two tricyclics treat
- What forms and doses they come in
- What side effects, adverse effects drug warnings, and potential drug interactions each has
- Plus, we’ll cover many FAQs we often receive from curious patients
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.
|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 per dose
• 10mg per dose
• 5% formula
|Conditions Treated||FDA-approved uses:|
• Major depressive disorder
• Diabetic neuropathy
• Postherpetic neuralgia or post-shingles skin pain
• Neurogenic cough
• Chronic pain
• Persistent myofascial pain
• Trigeminal neuralgia or painful shock sensations on the face
• Major depressive disorder
• Anxiety disorder
• 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
• Nausea and vomiting
• Sensitivity to sunlight
• Xerostomia or dry mouth
• Excessive sweating
• Breast gland tissue growth
• Increased need to urinate
• Abnormal sensations
• Urinary retention
• Changes in blood sugar levels
• Galactorrhea or nipple discharge
• Skin rash
• Itchy skin
|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
• Hearing loss
• Muscle spasms, stiffness, twitching
|Warnings For Use||Drug interactions: |
• Blood thinning medications like Warfarin
• Thyroid Supplements
• Anticholinergic drugs
• Thyroid supplements
• Anticholinergic drugs
• Some blood pressure medications: clonidine
• MAO inhibitors: isocarboxazid, linezolid, metaxalone, methylene blue
• St. John's Wort
• Drugs to treat irregular heart rate
Pamelor and Doxepin Are the Same Class of Antidepressants (Tricyclics)
Pamelor and Doxepin 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.
What Are Tricyclics?
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 Doxepin 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.
Pamelor and Doxepin Are Both Used To Treat Major Depressive Disorder
While Pamelor and Doxepin 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.
What Else Does Pamelor Treat?
Pamelor (Nortriptyline) is primarily prescribed to treat MDD. That said, it can also be used off-label to treat several issues outside of depression.
Off-label Uses for Pamelor
- Chronic pain: Pamelor can be effective in treating chronic pain conditions, such as neuropathic pain, migraine headaches, and fibromyalgia.
- Anxiety disorders: Pamelor may be prescribed off-label to treat anxiety disorders, such as generalized anxiety disorder (GAD), panic disorder, and social anxiety disorder.
- Attention deficit hyperactivity disorder (ADHD): Pamelor may be used off-label in combination with other medications to treat ADHD, particularly in cases where stimulant medications are not effective.
What Else Does Doxepin Treat?
Doxepin (Silenor) is most commonly used to treat depression and anxiety. However, like Pamelor, it also has been prescribed off-label to treat other issues.
Off-label Uses for Doxepin
- Insomnia: Doxepin has been found to be effective in treating insomnia, particularly when given at a low dose. It is often prescribed off-label for this purpose, as it has sedative effects that can help individuals fall asleep and stay asleep.
- Anxiety disorders: Similar to Pamelor, Doxepin may also be prescribed off-label to treat anxiety disorders, such as GAD, panic disorder, and social anxiety disorder.
- Chronic pain: Doxepin, like Pamelor, is also been effective at treating chronic pain conditions, particularly neuropathic pain. It may be used off-label in cases where other pain medications have been ineffective.
Doses, Dosage Form, and Side Effects of Doxepin
Doxepin 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.
Common Doxepin Doses and Forms
Doxepin 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.
Common Doxepin Side Effects
Doxepin has some possible side effects you should be aware of before taking this antidepressant.
Common side effects include:
- Dry mouth
- Blurred vision
- Trouble urinating
- Stomach ache
- Weight gain
- Changes in how food tastes
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.
- Suicidal ideation or thoughts of self-harm
- Worsening anxiety
- Agitation or restlessness
- Panic attacks
- New or worsened irritability
- Aggression, anger, or violent behavior
- Unusual changes in mood or behavior
- Difficulty urinating or pain when urinating
Common Doxepin Drug Interactions
Doxepin 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 Doxepin, potentially leading to drug interactions.
Some drugs that may interact with Doxepin include:
- Monoamine oxidase inhibitors (MAOIs): Concurrent use of Doxepin with MAOIs can increase the risk of serotonin syndrome, a potentially life-threatening condition that can cause agitation, confusion, rapid heartbeat, high blood pressure, and other symptoms.
- Other antidepressants: Concurrent use of Doxepin with other antidepressants, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and other tricyclic antidepressants, can increase the risk of serotonin syndrome.
- Benzodiazepines and other sedatives: Concurrent use of Doxepin with benzodiazepines, such as diazepam or lorazepam, or other sedatives, such as zolpidem, can increase the sedative effects of Doxepin.
- Anticholinergic medications: Concurrent use of Doxepin with anticholinergic medications, such as diphenhydramine or oxybutynin, can increase the risk of anticholinergic side effects, such as dry mouth, constipation, and urinary retention.
- Drugs that affect liver enzymes: Concurrent use of Doxepin with drugs that inhibit or induce liver enzymes, such as cimetidine or rifampin, can affect the metabolism and clearance of Doxepin, potentially leading to drug interactions.
How Much Does Doxepin Cost?
The price of Doxepin 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 generic Doxepin, Silenor.
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Doses, Dosage Form, and Side Effects of Pamelor
Pamelor doesn’t come in as many forms as Doxepin, 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.
Common Pamelor Doses and Forms
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 Pamelor Side Effects
Common side effects of Pamelor may dissipate over time as your body gets used to the medication. Those side effects include the following.
- Increased heart rate
- Blurred vision
- Urinary retention
- Dry mouth
- Weight gain or loss
- Dizziness when you stand up
- Tingly feeling
- Lack of coordination
- Unpleasant taste
- Ringing in your ears
- Breast swelling
- Decreased sex drive
- Difficulty orgasming
If you experience persistent unwanted side effects, you must talk with your mental health provider about your options before abruptly stopping Pamelor.
Common Pamelor Drug Interactions
Like Doxepin, 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:
- Monoamine oxidase inhibitors (MAOIs): Taking Pamelor while also on MAOIs can increase the risk of serotonin syndrome, much like Doxepin. Symptoms of serotonin syndrome are agitation, confusion, rapid heartbeat, high blood pressure, and other symptoms.
- Other antidepressants: Taking Pamelor while on other antidepressants, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and other tricyclic antidepressants, can also increase the risk of serotonin syndrome.
- Anticholinergic medications: Like doxepin, taking Pamelor with anticholinergic medications can increase the risk of anticholinergic side effects, such as dry mouth, constipation, and urinary retention.
- Central nervous system (CNS) depressants: Concurrent use of Pamelor with CNS depressants, such as benzodiazepines or opioids, can increase the sedative effects of Pamelor and increase the risk of respiratory depression.
- Drugs that affect liver enzymes: Like doxepin, taking Pamelor with drugs that inhibit or induce liver enzymes can affect Pamelor’s metabolization in the body.
How Much Does Pamelor Cost?
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.
Do I Need A Prescription for Pamelor or Doxepin?
Yes, both Pamelor and Doxepin 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.
Other Tricyclic Side Effects
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.
What is Serotonin Syndrome?
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:
- Sleep issues
- Rapid heart rate
- High blood pressure
- Dilated pupils
- Loss of muscle coordination or twitching
- Muscle rigidity
- Excessive sweating
- Shivering or goosebumps
If you experience any of those symptoms, contact your care provider immediately, as this syndrome can be fatal if left untreated.
Pregnancy and Breastfeeding on Tricyclics
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.
Increased Bleeding Risk With Tricyclics
Because tricyclic antidepressants influence serotonin levels, there’s an increased risk of bleeding. 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.
Doxepin and Pamelor Frequently Asked Questions
What is Doxepin?
Doxepin 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.
What is Pamelor?
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.
Are Doxepin, Pamelor, and other Tricyclics the same antidepressant?
While Doxepin 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.
What’s better for anxiety? Doxepin or Pamelor?
Doxepin 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.
What’s better for depression? Doxepin or Pamelor?
Both Doxepin and Pamelor can treat symptoms of depression. That said, both have different drug interactions and side effects. Doxepin 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.
Can I drive on antidepressants like Doxepin or Pamelor?
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.
Can I drink alcohol on Doxepin or Pamelor?
Drinking alcohol on Doxepin 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.
Does it matter what time of day I take Doxepin or Pamelor?
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.
How Klarity Helps You Access Online Depression Treatment
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!
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