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Tricyclic antidepressants

Dear bpac,

Many thanks for your report on antidepressants prescribed to elderly people.

Please don't think for one moment that I treat depression in the elderly with TCAs. If I use TCAs it is for the treatment of insomnia for people waking up in the early morning hours.

TCAs appear to be well tolerated in a very low dose (10-20 mg) even by the elderly. I also use TCAs in a moderate dose, up to 50mg, for chronic pain syndrome mostly for younger or middle aged people and I have tried it in a low dose to help people with smoking cessation.

I think it is well known that the treatment of depression with TCA in any age group has long become obsolete since the SSRIs have been developed. Apart from the well known side effects I still remember the suicide attempts with TCAs we used to see many years ago when I was a senior medical registrar.

Runa Rao
GP, Tauranga

Many other GPs also told us that they are prescribing TCAs in elderly people for conditions other than depression - usually for neuropathic pain. TCAs can be associated with significant toxicity in overdose and this may influence prescriber choice. TCAs are an effective medication and can be used appropriately for several indications. However for depression in elderly people, consider an SSRI first.

The purpose of the prescribing report was to highlight the fact that if a TCA is prescribed, nortriptyline is the best choice for an elderly person as it has less sedative and anticholinergic effects than other TCAs.

Current guidance for missed combined oral contraceptive pills

Dear bpac,

Leaflets from different contraceptive pill packets contain differing advice regarding missed pills. What is the currently recommended advice for missed pills?

GP, Dunedin

Missing combined oral contraceptive pills

The New Zealand Family Planning Association (FPA) developed guidance for missed pills in 2006. Their advice is:

Missed one pill:

  • The missed pill should be taken as soon as it is remembered and then carry on taking remaining pills as usual. This may mean taking two hormone pills together. No additional precautions are required.
  • Consider emergency contraception if the missed pill was from the first seven days of the pack and the woman has had unprotected intercourse in the previous pill free interval. The risk of pregnancy is greatest when pills are missed at the beginning of the pack, extending the pill-free week, as efficacy may be reduced.

Missed two pills within a seven day period:

  • An additional contraceptive method is required or intercourse should be avoided until seven active pills have been taken.
  • Consider emergency contraception if sexual intercourse has occured before the seven active pills have been taken.
  • If missed pills are in the week before inactive tablets/pill-free week, the inactive pills/pill-free week should be missed and the next pack started after the active pills in the current pack are finished.

Vomiting and diarrhoea for more than 24 hours requires an additional contraceptive method until seven active pills have been taken. This may require skipping the pill-free week/inactive pills.

Missing progestogen only pills

If a progestogen only pill has been missed by more than three hours (or more than twelve hours for Cerazette), the missed pill should be taken as soon as possible. An additional contraceptive method is required or intercourse should be avoided until two days of pills have been taken. This is also required if a women vomits within three hours of taking a pill or if she has diarrhoea. Emergency contraception may be required if unprotected intercourse occurs in these two days.1

See Combined oral contraceptive: Issues for current users article for information on managing drug interactions with oral contraceptives e.g. antibiotics.


  1. National Prescribing Service Newsletter. Hormonal contraceptives: tailoring for the individual. Available from: Accessed February 2008

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