B A C K

Treating Depression

Introduction Throughout this factsheet, 'depression' means depressive illness. This is very different to the normal, brief periods of feeling down that all people occasionally have in response to circumstances in their day-to-day lives. It is a serious and persistent feeling of sadness that can be accompanied by changes in patterns of sleep, appetite, concentration and energy. It can also sometimes involve feelings that life is not worth living or even thoughts of suicide.	Depression is treatable and there are many effective medicines available
Why treat depression? It is treatable. A number of effective treatments are available for depression and the right one or the right combination of them can usually be found for each person with the illness. It does not just quickly go away on its own, and it can be a disabling and potentially serious condition. In a small number of cases it can be fatal because of suicide or because of self-neglect if the sufferer is no longer able to look after his/herself as a result of the illness.
Types of treatment There are many types of treatment for depression and some of the most frequently used include: antidepressant tablets. 'talking treatments', such as counselling and various types of psychotherapy. mood stabilising medications. support with day-to-day matters while ill or recovering. Treatments that are used less often, but which can be helpful, especially in depression that is severe, of a specific type, or has proved difficult to treat include: electroconvulsive therapy (ECT) special types of operation (psychosurgery) bright light therapy for seasonal affective disorder (SAD). Lastly, there are potential treatments that are either still experimental, or for which more evidence needs to be found before they can be considered truly effective and safe: >herbal remedies (eg St John's wort). trans-cranial magnetic stimulation (TMS), which involves applying brief magnetic pulses to the brain. This is done with the patient awake and sitting in a chair. A doctor holds an electric coil near to the head that emits repeated short magnetic pulses. The procedure is painless. At the present time, TMS is still under investigation as a treatment for depression, but current evidence suggests that it may be as effective as ECT but safer. Broadly speaking, treatments for depression can be broken down into two types. Firstly, there are those that aim to correct the chemical and biological abnormalities that occur in the illness. These are: antidepressants, mood stabilising medications, ECT and psychosurgery. Secondly, there are the psychological ones - 'talking treatments'. These involve regular appointments to talk to a professional person who is skilled in a particular type of counselling or psychotherapy to help with depression. The biological and psychological treatments are certainly not mutually exclusive and are often used in combination. Neither should one group of treatments or therapies be considered better than the other. The treatment (or combination of treatments) used should be the one most likely to help the person when all the different factors that have led to their illness are taken into account. This is the reason that approaching a professional is so important in deciding how best to cope with and treat depression. Antidepressant tablets There are a number of different groups of these and they include: tricyclic antidepressants (TCAs), eg amitriptyline, imipramine, lofepramine. selective serotonin re-uptake inhibitors (SSRIs), eg fluoxetine, paroxetine, citalopram, escitalopram. monoamine oxidase inhibitors (MAOIs), eg phenelzine, tranylcypromine, moclobemide. other medications that do not quite fit neatly into these groups, but that have effects similar to one or more of these groups (eg venlafaxine, mirtazepine, reboxetine, trazodone hydrochloride). The oldest antidepressants are the monoamine-oxidase inhibitors (MAOIs) and tricylic antidepressants (TCAs). The TCAs are still in wide use today and remain effective medicines. The MAOIs require a special diet to avoid unpleasant and potentially serious side effects, and they can interact with many other medicines. They are therefore generally used only for people whose depression has not responded to other treatments. The SSRIs are a much newer group of antidepressants, but they have been widely and successfully used for a number of years. How do they work? All of these medications work by boosting one or more chemicals (called neurotransmitters) in the nervous system. These chemicals may be present in insufficient amounts in depression, resulting in the symptoms of the illness. Do they work straight away? No. All antidepressants take a minimum of two weeks (and sometimes up to eight weeks) to start to work, and once they have started working the depression recovers gradually. It is vitally important, therefore, that if a person is given antidepressants they should keep taking them regularly, even if they don't seem to make much difference to begin with. Are they addictive? No. Some antidepressants can cause mild unpleasant effects if they are stopped very suddenly, but even these can normally be avoided if the medication is tailed off over a short time. How long should they be taken for? A rule of thumb is that antidepressants should be taken for at least six months after the person has recovered. This reduces the risk of the depression coming back again. A few people whose depression does return every time they come off antidepressants may need to be on treatment on a long-term basis. So which is the best type to take? There is no evidence to suggest that any one antidepressant or antidepressant group is better than any other in terms of the number of people who will benefit from it. (Generally around two-thirds of people will find that their symptoms improve on any particular medication). But one may be a better choice than another on the grounds of its side effects: for instance a person who finds that their sleep is disturbed may benefit from an antidepressant that is also quite sedative. By contrast, someone who is sleeping reasonably and has to be able to listen out for their children would clearly find this effect a problem, and would be better with a non-sedative medication. If an antidepressant from one group does not work very well, then there is a good chance that one from another group may work. Mood stabilisers In depression, these drugs are used to boost the effects of antidepressants. The best-known mood stabiliser is lithium. It is also the best-proven one, but one drawback is that regular blood tests are needed to check its level. (Lithium is also used in bipolar affective disorder - 'manic depression'.) There are some newer mood stabilisers available now that offer alternatives to lithium. Electroconvulsive therapy Electroconvulsive therapy (ECT) is a treatment for depression that has been used for many decades, but one that remains controversial. The facts are: it is a very effective treatment for depression - perhaps the single most effective treatment there is. it is especially effective for severe depression and depression that has a lot of physical symptoms, such as changes in appetite, sleep and concentration. it is as safe as any minor procedure that needs a general anaesthetic. it can be lifesaving as it can work more quickly than antidepressant drugs. there is no good evidence for any permanent damage to the nervous system. Like all treatments, ECT does have some side effects. These can include: headache. forgetfulness around the time of treatment. Psychological treatments Psychological treatments for depression are many and varied. They range from the psychological support provided when someone has the regular opportunity to talk about their feelings to a professional such as a GP or psychiatrist, right through to very specialised forms of psychotherapy. They include: supportive counselling analytic psychotherapy cognitive behavioural therapy (CBT) cognitive analytic therapy. There is no evidence to suggest that any one type of therapy is better than any other, and reasonably good evidence that, for the right person, psychotherapy can be as successful as antidepressant medication in milder depression. It can also be used very successfully in conjunction with antidepressants and may add to the effect of the latter. Having said this, psychotherapy is not the treatment of choice for everyone (in just the same way antidepressants are not the right treatment for everybody). If it is used, the type of psychotherapy that will best suit any individual has to be carefully considered, highlighting the need for an experienced clinician (e. GP, psychiatrist, nurse, psychologist) to be involved in this decision. Psychotherapy can take place with: individuals couples families groups. It depends on the specific problems and the best ways of approaching them. Psychotherapy is carried out by a wide range of health professionals including: doctors nurses psychologists occupational therapists social workers. Psychosurgery Psychosurgery is a form of specialised brain surgery and has been used to treat depressive illness that has failed to respond to long trials of many other treatments. It is performed very infrequently nowadays, and although it does not work for all those who undergo it, it can have beneficial effects. Social therapies This term refers to things that can be done to help a person to function as well as possible while they are ill and, crucially in depression, help them to rebuild/strengthen their self-esteem as they recover. Social therapies can range from planning activities to help someone avoid brooding on problems that may worsen depression, to schemes designed with the help of health and social work staff to help someone build back up to their normal routine. Depression that is resistant to treatment Whilst most depressive illnesses will be successfully treated with one of the treatments mentioned, some will not respond as well and may need more specialised combinations of therapies than others. People with these more difficult to treat depressive illnesses should be referred to a psychiatrist. Where does treatment take place and who arranges it? The vast majority of depressive illness is treated by GPs. Many GPs have counsellors who can offer supportive sessions. Community psychiatric nurses (CPNs) may be available via some GPs or via hospital psychiatry departments. GPs will refer patients to psychiatrists and community psychiatric teams (made up typically of psychiatrists, nurses, social workers and psychologists) for further help if needed. Most people seeing members of a psychiatric team will have appointments at outpatient clinics or at home. Occasionally, if depression is very severe, an admission to hospital may be needed to offer more intensive help. In summary Depression is a readily treatable illness. There are many treatments available. Even people with the most severe and difficult to treat depressive illnesses can normally be helped. Dr Adrian Lloyd and the Newcastle Affective Disorders Group are working with NetDoctor in developing the Depression Community. Tricyclic antidepressants Tricyclic antidepressants (TCAs) are one of the oldest classes of antidepressants and are still used extensively. Before the introduction of selective serotonin re-uptake inhibitors (SSRIs), TCAs were the standard treatment for depression. Even today, doctors are encouraged to prescribe TCAs as first-line treatment for depression, due to their effectiveness and the extensive experience we have in using TCAs over many years. How do TCAs work? Within the brain, there are many naturally occurring chemical messengers called neurotransmitters. These chemicals are involved in controlling or regulating bodily functions. Two of these chemicals, noradrenaline and serotonin, are involved in the control and regulation of mood. When depression occurs, there may be a decreased amount of these two chemicals released from nerve cells in the brain. When these chemicals are released from nerve cells they act to lighten mood. When they are reabsorbed into the nerve cells, they no longer have an effect on mood. TCAs work by preventing this reabsorption of noradrenaline and serotonin back into the nerve cells. This prolongs the mood-lightening effect of any released noradrenaline and serotonin and in this way helps to relieve depression. How long do TCAs take to work? TCAs can take a while to have an effect. You may experience an effect on your mood within two weeks, however, the full benefits of treatment with TCAs may not occur for a further two to four weeks. Which one is best for me? The choice of TCA depends on a number of factors. TCAs should generally not be used if you have a heart problem, are breastfeeding, pregnant or have a liver problem (please see individual medicine information for specific cautions). Some TCAs, e.g. amitriptyline and dothiepin, cause more drowsiness than others and are useful for treating depression in people who are also anxious and agitated. TCAs that cause less drowsiness, e.g. imipramine and lofepramine, are useful for withdrawn and lethargic people. Lofepramine is also often used to treat depression in the elderly. The most common side effects experienced with TCAs include constipation, difficulty in urinating, blurred vision, dry mouth, weight gain, sexual dysfunction and drowsiness. TCAs tend to cause more troubling side effects than some of the newer antidepressants, such as SSRIs. Manufacturer: Non-proprietary Active ingredient: Imipramine hydrochloride How does it work? Imipramine belongs to a group of medicines known as tricyclic antidepressants (TCA). When depression occurs, there may be a decreased amount of the chemicals noradrenaline and serotonin released from nerve cells in the brain. When these chemicals are released from nerve cells they act to lighten mood. When they are reabsorbed into the nerve cells, they no longer have an effect on mood. Imipramine works by preventing this re-absorption of noradrenaline and serotonin back into the nerve cells. Therefore, it helps prolong the mood-lightening effect of any released noradrenaline and serotonin. This helps relieve depression. The full benefits of treatment with imipramine may not appear for two to four weeks. Imipramine also blocks receptors in other areas of the body resulting in side-effects such as urinary retention. Therefore, imipramine may also be used in the treatment of bed-wetting (nocturnal enuresis)in children. When used for this purpose, imipramine should generally only be used for a maximum of three months. What is it used for? Bedwetting (nocturnal enuresis). Depression. Warning! Do not drink alcohol whilst taking this medicine. This medicine may reduce the ability to drive or operate machinery safely. This medication may cause low blood sodium levels (hyponatraemia). This can result in drowsiness, confusion or convulsions. Avoid abrupt withdrawal of this medication. Sudden discontinuation of this medication may result in insomnia, irritability and excessive sweating. The use of this medication in children to treat nocturnal enuresis may result in behavioural changes. Ongoing use of this medicine while wearing contact lenses may result in damage to the surface of the eye. Long-term use of this medicine may result in tooth decay. It is important to visit your dentist regularly. Regular blood tests should be conducted. Notify your doctor if any signs of fever or sore throat develop. If you should require local or general anaesthesia, it is important that you inform your anaesthetist you are taking this medicine. Use with caution in Elderly people. Enlarged prostate (prostatic hypertrophy). Epilepsy. Glaucoma. Hyperthyroidism. Liver disease. Long-term ongoing constipation. Low blood pressure (hypotension). People taking thyroid medication. Predisposition to fit (seizure) e.g. due to alcohol/drug withdrawal, brain damage, other medicines. Psychotic illness. Severe kidney disease. Treatment for severe depression where a convulsion is produced by passing an electric current through the brain (electroconvulsive therapy, ECT). Tumour of the adrenal gland (phaeochromocytoma). Not to be used in Children under 6 years of age. Closed angle glaucoma. Defect of the heart's electrical message pathways resulting in decreased function of the heart (heart block). Difficulty in passing urine (urinary retention). Hypersensitivity to some other tricyclic antidepressants (TCAs). Irregular heart beats (arrhythmias). Mania. Recent heart attack. Severe liver disease. This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy. If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately. Pregnancy and breastfeeding Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine. This medicine should not be used during pregnancy. This medicine is present in breast milk. It is recommended not to use this medicine when breastfeeding or, alternatively, not to breastfeed when taking this medicine. Seek medical advice from your doctor. Label warnings This medication may cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholic drink. Side effects Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Because a side effect is stated here, it does not mean that all people using this medicine will experience that or any side effect. Difficulty in passing stools (constipation). Blurred vision. Faster than normal heart beat (tachycardia). Difficulty in passing urine (urinary retention). Dry mouth. Drowsiness. Confusion. Shaking, usually of the hands (tremor). Agitation. Blood disorders. A drop in blood pressure that occurs when going from lying down to sitting or standing, which results in dizziness and lightheadedness (postural hypotension). Sexual problems. The side effects listed above may not include all of the side effects reported by the drug's manufacturer. For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist. How can this medicine affect other medicines? Imipramine should not be taken with a monoamine oxidase inhibitor (MAOI) antidepressant. Treatment with imipramine should not be started until 3 weeks after stopping a MAOI. Conversely, treatment with a MAOI should not be started until 3 weeks after stopping imipramine. Imipramine should also not be taken with moclobemide. Imipramine blood levels may be increased by: Alprazolam. Anti-psychotic medication such as chlorpromazine. Cimetidine. Disulfiram. Fluoxetine. Fluvoxamine. Methylphenidate. Quinidine. Imipramine blood levels may be decreased by: Barbiturates. Carbamazepine. Imipramine may increase the blood levels of the anti-epileptic medicines carbamazepine and phenytoin. Imipramine may decrease the blood pressure lowering effect of: Bethanidine. Debrisoquine. Guanethidine. There may be a sudden and marked increase in blood pressure and heart rate when imipramine is taken with medications causing vessel constriction such as phenylephrine and adrenaline. These medicines should not be taken together. There may be an increase in the risk of arrhythmias occurring when imipramine is taken with quinidine or thioridazine. These medicines should not be taken together. Imipramine may increase the anti-clotting effect of warfarin. There may be an increase in side-effects such as dry mouth, constipation and blurred vision when imipramine is taken with other anticholinergic medicines e.g. hyoscine. Imipramine may increase the sedating effects of alcohol. Other medicines containing the same active ingredients Tofranil. Manufacturer: Merck Active ingredient: Lofepramine How does it work? Lofepramine belongs to a group of medicines known as tricyclic antidepressants (TCA). When depression occurs, there may be a decreased amount of the chemicals noradrenaline and serotonin released from nerve cells in the brain. When these chemicals are released from nerve cells they act to lighten mood. When they are reabsorbed into the nerve cells, they no longer have an effect on mood. Lofepramine works by preventing this re-absorption of noradrenaline and serotonin back into the nerve cells. Therefore, it helps prolong the mood-lightening effect of any released noradrenaline and serotonin. This helps relieve depression. What is it used for? Depression. Warning! Do not drink alcohol whilst taking this medicine. This medicine may reduce the ability to drive or operate machinery safely. This medication may cause low blood sodium levels (hyponatraemia). This can result in drowsiness, confusion or convulsions. Avoid abrupt withdrawal of this medication. Sudden discontinuation of this medication may result in insomnia, irritability and excessive sweating. Use with caution in Blood disorders. Cardiovascular disease. Closed angle glaucoma. Decreased kidney function. Decreased liver function. Difficulty in passing urine (urinary retention). Enlarged prostate (prostatic hypertrophy). History of epilepsy. Hyperthyroidism. Life long inherited blood diseases which can cause a variety of symptoms, including mental health problems (porphyrias). Recent convulsions. Not to be used in Children. Defect of the heart's electrical message pathways resulting in decreased function of the heart (heart block). Hypersensitivity to some other tricyclic antidepressants (TCAs). Irregular heart beats (arrhythmias). Mania. Recent heart attack. Severe liver disease. Severe liver disease. This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy. If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately. Pregnancy and breastfeeding Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine. Manufacturer advises to avoid in pregnancy as no safety information is available. Discuss with your doctor. This medicine is present in breast milk. It is recommended to avoid the use of this medicine when breastfeeding. Seek medical advice from your doctor. Label warnings This medication may cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholic drink. Side effects Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Because a side effect is stated here, it does not mean that all people using this medicine will experience that or any side effect. Blurred vision. Faster than normal heart beat (tachycardia). Difficulty in passing urine (urinary retention). Dry mouth. Drowsiness. Confusion. Blood disorders. Disturbances of the gut such as diarrhoea, constipation, nausea, vomiting or abdominal pain. Low blood pressure (hypotension). Sexual problems. The side effects listed above may not include all of the side effects reported by the drug's manufacturer. For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist. How can this medicine affect other medicines? Lofepramine should not be taken with a monoamine oxidase inhibitor (MAOI) antidepressant. Treatment with lofepramine should not be started until 2 weeks after stopping a MAOI. Lofepramine blood levels are decreased by barbiturates. Lofepramine may increase the sedating effects of alcohol. There may be a sudden and marked increase in blood pressure and heart rate when lofepramine is taken with medications causing vessel constriction such as phenylephrine and adrenaline. These medicines should not be used together. Lofepramine may decrease the blood pressure lowering effect of: Bethanidine. Debrisoquine. Guanethidine. Lofepramine may increase the anti-clotting effect of warfarin. Other medicines containing the same active ingredients Gamanil. Lomont. Manufacturer: Novartis Active ingredient: Clomipramine hydrochloride How does it work? Clomipramine belongs to a group of medicines known as tricyclic antidepressants (TCA). When depression occurs, there may be a decreased amount of the chemicals noradrenaline and serotonin released from nerve cells in the brain. When these chemicals are released from nerve cells they act to lighten mood. When they are reabsorbed into the nerve cells, they no longer have an effect on mood. Clomipramine works by preventing this re-absorption of noradrenaline and serotonin back into the nerve cells. Therefore, it helps prolong the mood-lightening effect of any released noradrenaline and serotonin. This helps relieve depression. Clomipramine also blocks receptors in other areas of the body resulting in side-effects such as drowsiness. Therefore, clomipramine may be particularly useful in the treatment of depression where sedation is required. The full benefits of treatment with clomipramine may not appear for two to four weeks. Clomipramine may also be used in the treatment of obsessive disorders such as obsessive-compulsive disorder and phobia disorders. It is not fully understood how clomipramine works in these conditions but it is thought to be related to the increased effect of serotonin and noradrenaline in the brain. The first few days of clomipramine therapy for these disorders may involve an increase in anxiety and panic, however, this problem generally subsides within the first two weeks of treatment. In addition, clomipramine may be used to treat cataplexy associated with narcolepsy. Clomipramine is thought to be of use in this condition by increasing the stimulating effect of the chemical noradrenaline in the brain. What is it used for? A condition where people repeatedly and suddenly fall to the ground but remain conscious (cataplexy); this is often associated with the sudden and overwhelming need to sleep (narcolepsy). Depression. Phobias or obsessional states. Warning! Do not drink alcohol whilst taking this medicine. This medicine may reduce the ability to drive or operate machinery safely. This medication may cause low blood sodium levels (hyponatraemia). This can result in drowsiness, confusion or convulsions. Avoid abrupt withdrawal of this medication. Sudden discontinuation of this medication may result in insomnia, irritability and excessive sweating. Ongoing use of this medicine while wearing contact lenses may result in damage to the surface of the eye. This medicine may cause blood, heart or liver disorders. Therefore blood tests should be done periodically. Notify your doctor if any symptoms of sore throat or fever develop. Long-term use of this medicine may result in tooth decay. It is important to visit your dentist regularly. If severe psychiatric or nervous system reactions occur, this medicine should be withdrawn. Use with caution in Agitation. Elderly people. Enlarged prostate (prostatic hypertrophy). History of epilepsy. Hyperthyroidism. Increased pressure within the eye. Long-term ongoing constipation. People taking thyroid medication. Predisposition to fit (seizure) e.g. due to alcohol/drug withdrawal, brain damage, other medicines. Psychotic illness. Treatment for severe depression where a convulsion is produced by passing an electric current through the brain (electroconvulsive therapy, ECT). Tumour of the adrenal gland (phaeochromocytoma). Not to be used in Children. Closed angle glaucoma. Defect of the heart's electrical message pathways resulting in decreased function of the heart (heart block). Difficulty in passing urine (urinary retention). Heart failure. Hypersensitivity to some other tricyclic antidepressants (TCAs). Irregular heart beats (arrhythmias). Mania. Recent heart attack. Severe liver disease. This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy. If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately. Pregnancy and breastfeeding Certain medicines should not be used during pregnancy or breastfeeding. However, other medicines may be safely used in pregnancy or breastfeeding providing the benefits to the mother outweigh the risks to the unborn baby. Always inform your doctor if you are pregnant or planning a pregnancy, before using any medicine. Manufacturer advises to avoid in pregnancy as no safety information is available. Discuss with your doctor. This medicine is present in breast milk. It is recommended to avoid the use of this medicine when breastfeeding. Seek medical advice from your doctor. Label warning This medication may cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholic drink. Side effects Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Because a side effect is stated here, it does not mean that all people using this medicine will experience that or any side effect. Headache. Difficulty in passing stools (constipation). Blurred vision. Difficulty in passing urine (urinary retention). Dry mouth. Drowsiness. Shaking, usually of the hands (tremor). Nausea. Involuntary muscle movements such as tremors or twitching. Sweating. Weight gain. Dizziness. Sexual problems. The side effects listed above may not include all of the side effects reported by the drug's manufacturer. For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist. How can this medicine affect other medicines? Clomipramine should not be taken with a monoamine oxidase inhibitor antidepressant (MAOI) or moclobamide. Treatment with clomipramine should not be started until 3 weeks after stopping a MAOI or moclobamide. Conversely, a MAOI should not be started until 3 weeks after clomipramine has been ceased. Moclobamide therapy may be started less than 3 weeks after ceasing clomipramine. Avoid taking any selective serotonin reuptake inhibitor antidepressants (SSRI) such as fluoxetine or fluvoxamine when taking clomipramine. This combination may result in increased clomipramine blood levels. Clomipramine blood levels are increased by cimetidine. Clomipramine blood levels are decreased by barbiturates. There may be a sudden and marked increase in blood pressure and heart rate when clomipramine is taken with medications causing vessel constriction such as phenylephrine and adrenaline. These medicines should not be used together. Clomipramine may decrease the blood pressure lowering effect of: Bethanidine. Clonidine. Debrisoquine. Guanethidine. There may be an increase in side-effects such as drowsiness and dry mouth when clomipramine is taken with other anticholinergic medicines such as hyoscine. Clomipramine may increase the anticlotting effect of warfarin. Clomipramine may marginally increase the sedating effects of alcohol. Other medicines containing the same active ingredients Anafranil injection. Anafranil SR. Clomipramine hydrochloride.