Table 3.

Treatment information about the tricyclic antidepressants (TCAs) imipramine and nortriptyline: the decision to start a TCA treatment balances the documented efficacy and the increased risk of side-effects in elderly patients

Effect	Better than placebo in randomized controlled trials
Dose in elderly patients	Imipramine: 50–100 mg/day
	Nortriptyline: 25–75 mg/day
	Start low – go slow!
Recommended plasma	Imipramine (plus desipramine): 175–350 ng/ml
levels at steady state	Nortriptyline: 50–150 ng/ml
Examples of common side-effects	Orthostatic hypotension (less common with nortriptyline), dizziness, tachycardia, dry mouth, blurred vision, disturbance of accommodation, constipation, and drowsiness
Examples of less common side-effects	Arrhythmias, heart block, confusional states, seizures, urinary retention, paralytic ileus, drug fever, skin rash, bone marrow depression, altered liver function, hypomania, and falls. Increased mortality in patients with ischemic heart disease. Pre-existing heart block gets worse during treatment
Pre-treatment examinations	Physical examination
	Measurement of orthostatic hypotension
	ECGBlood tests including liver enzymes

Table 3: Key points

• Around 40% of all COPD patients have severe depressive symptoms or clinical depression
• The six-item Hamilton Depression Subscale seems to be a useful screening tool
• Quality of life is strongly impaired in COPD patients and is more correlated with the presence of depressive symptoms than to the severity of COPD
• Nortriptyline, imipramine, pulmonary rehabilitation. and cognitive-behavioral therapy are effective treatment options
• Preliminary data suggest that co-morbid depression may be an independent protector for mortality
• Much more research is needed in this field