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Haley Cox
Vocal Pedagogy
Wednesday 4:30-6:20
Dr. Wade
Final Paper

The Effect of TCAs on the Voice

The music industry is hard. Its gritty, competitive, usually petty, and takes thick
skin to withstand. That may be part of the reason why creative artist is fifth on the top
ten professions with the highest rate of Depression. That is ironic, however, since people
with mental illnesses are more likely to be drawn to this sort of profession. Many people
puzzle over whether the high rates of Depression in these fields are causes or symptoms
of this type of work. [3]
In fact, the arts and entertainment career field has the second highest rate of drug
usage and fourth highest rate of alcoholism. When the statistics were broken down to age
and gender, it was surprising to find that the two factors had little to no impact on the
numbers. Far and wide, the data held up that arts and entertainment workers were right
behind hotel and restaurant workers in the drug category and below miners, construction,
hotels and restaurants in the alcohol category. [20]

When the actual

characteristics of the jobs
come into play, each could
be described as a high
stress and fast paced job. A
vicious cycle is often
formed with depressed
individuals and depressants

(such as alcohol or certain drugs), and since the arts and entertainment industry is so
closely linked with the consumption of these substances, it makes perfect sense that the
career field is fifth on the top ten careers most likely to result in depression.
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3-5% of the United States population suffers from Depression at some point
during their lives, the national percentage in 2014 being 6.7% of adults. [2] Of that 6.7
percent being treated, about 75% on average were prescribed anti-depressant medication,
and less than half of that number were treated with psychotherapy. In fact, the percentage
of people taking antidepressants from 1988-2008 rose nearly 400%. [5]

[5]

Americas knee-jerk reaction to mental or physical problems has now become a

prescription. That is in no way to say that medicine is invaluable or not necessary to those
who require it, but it is concerning that psychiatrists and psychologists seem more apt to
solely medicate the problem rather than address it by both medicine and therapy.
Furthermore, 38% of people medicated for disorders like OCD, GAD, Depression, etc.
have never had those illnesses, and 69% of people taking SSRIs (Selective Serotonin
Reuptake Inhibitors) have never experienced Depression. [4]
What exactly is Depression? The media, politicians, and our conservative aunts
and uncles all seem to have a very different opinion of it. The Mayo Clinic says:

Depression is a mood disorder that causes a persistent feeling of sadness

and loss of interest. Also called major depressive disorder or clinical
depression, it affects how you feel, think and behave and can lead to a
variety of emotional and physical problems More than just a bout of the
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blues, depression isn't a weakness and you can't simply "snap out" of it.
Depression may require long-term treatment. [1]

Harvard Health states:

It's often said that depression results from a chemical imbalance, but that
figure of speech doesn't capture how complex the disease is. Research
suggests that depression doesn't spring from simply having too much or too
little of certain brain chemicals. Rather, depression has many possible
causes, including faulty mood regulation by the brain, genetic vulnerability,
stressful life events, medications, and medical problems. It's believed that
several of these forces interact to bring on depression. [14]

While some may be caught in depressive episodes that last anywhere from a
month to years, some battle the illness over a lifetime. It is all contingent on ones body
chemistry and environment. Something as obscure as weather may play a huge part on
ones mood, a multitude of Americas suffer from SAD (Seasonal Affective Disorder), a
type of depression that occurs every year because of just that. While some battle the
illness part of the year, others are always affected because of the way their brains
chemistry works.

[15] [On the left, what brain function looks like while depressed, on the right, normal
brain function. Note the serious lack of activity in the frontal lobe]
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The stressful life events mentioned in Harvard Healths definition of Depression

are likely what puts the creative artist field on the list of the ten careers with the highest
rates of Depression. The high-stress and critical environment of the arts can be a breeding
ground for depression, among other mental illnesses and personal issues, coupled with
the higher rates of drug and alcohol usage in this career path. Like seeking out a career in
this field, specialists muse over whether the drug and alcohol usage are a symptom of
depression, what brings it forth, or a mixture of the two.
Because of this phenomena, many performers, if not the majority, have therapists
or counselors they confide in and seek help from because of depression or depressive
symptoms brought on by their environment. Therapists are not always used by the
mentally ill, however; many performers choose to confide in a therapist or counselor to
prevent depressive symptoms from occurring, or to simply have someone neutral to vent
to.

[23]
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Alternative medicine has also been rising in popularity, especially in the recent
decade. Therapies like acupuncture, massage therapy, and meditation are incredibly
popular, especially among those who are tentative to ingest medicine. Massage therapy is
especially good for singers due to the amount of tension we carry in our body from stress
and/or improper singing, and how strongly that muscle tension can affect our singing.
Personally, I know many performers, who take or have taken SSRIs with mixed
success. Medications are very personal, and while one medication may work well for one
person, it will not for another, especially if the two individuals have differing levels of
illness or a combination of different illnesses. Additionally, not all individuals suffering
from a mental illness require medication, especially if it is not caused by brain chemistry
or the ingestion of depressants such as alcohol.
So what sorts of medicines are prescribed to treat Depression? Antidepressants are
the third most prescribed medicine overall in America, so there are many to choose from.
The main categories are: SSRIs (Selective Serotonin Reuptake Inhibitors), SNRIs
(Serotonin and Norepinephrine Reuptake Inhibitors), TCAs (Tricyclic Antidepressants),
MAOIs (Monoamine Oxidase Inhibitors), and an a la cart of unique antidepressants with
brands like Bupropion and Trazodone. [6]
The most popular and commonly prescribed is the SSRI category, with leading
brands such as Celexa (Citalopram) and Prozac (Fluoxetine), but the drug that has the
most side effects is the second most popular category: TCA, with drugs like Elavil
(Amitriptyline) and Prothiaden (Dosulepin). [21] [6]
While both classes of drug produce an equal response rate of 60% and are equally
effective in treating moderate depressive disorders and panic disorders, TCAs are proven
to be more effective in in-patients and patients with severe depressive disorders. TCAs
also have higher remission rates than SSRIs, 44.1% compared to 37.7%. [22]

[21]
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How do TCAs work?

Cyclic antidepressants ease depression by impacting chemical

messengers (neurotransmitters) used to communicate between brain cells.
Like most antidepressants, cyclic antidepressants work by ultimately
effecting changes in brain chemistry and communication in brain nerve
cell circuitry known to regulate mood, to help relieve depression.

Cyclic antidepressants block the absorption (reuptake) of the

neurotransmitters serotonin (ser-o-TOE-nin) and norepinephrine (nor-ep-
ih-NEF-rin), increasing the levels of these two neurotransmitters in the
brain. Cyclic antidepressants also affect other chemical messengers, which
can lead to a number of side effects. [1]

Notable side effects from this category include

constipation, dizziness, and dry mouth. The dryness in
mouth and throat is the most detrimental to singers, and is
also the center of my thesis: Does taking TCAs have a
detrimental impact on a singers voice and vocal
anatomy?
According to a study done by the National Center
for Biotechnology Information, specialists took saliva
samples and analyzed the flow rates from normal, non-
An amitriptyline molecule [8]
medicated controls and patients on antidepressants. A portion
of the medicated patients were on amitriptyline and dothiepin (TCAs), and the other
portion were on fluoxetine and paroxetine (SSRIs). After examination, there was a 58%
reduction in flow rate from the TCA group compared to the controls and the SSRI group,
a decrease in sodium ions, and an increase in potassium ions, causing dryness in the
mouth and throat. [7]
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What does this mean for a singer? As someone who

uses their mouth and throat more than any other person,
what effect does dryness caused by TCAs have on a
singers voice and vocal anatomy? When the larynx, nasal
cavity, and vocal folds are not moistened and lubricated, A paroxetine molecule [9]
the edges of the fold become irritated and produce a heavier, raspier tone quality. To
combat this, singers will put more pressure on the larynx and send more air through,
which strains the voice. [10]

[12]

Singing on dry, un-moistened chords can

result in vocal calluses, pre-nodules,
nodules, polyps, or even a vocal hemorrhage
due to the thinning of the blood. The vocal
folds are what experience most of the
damage. Irritated, callused folds are inefficient for
producing healthy sound and singing in a dynamic range, and will ultimately end a
singers career if they do not get them fixed.
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The more a singer tries to overcompensate for their decreasing vocal quality due
to vocal damage, the more vocal damage they accrue. It begins with the edges of the
vocal chords becoming irritated or enflamed due to the lack of lubrication. Next, a
specific area with the highest concentration of irritation begins to harden over, much like
a callus on the hand (resulting in a nodule) or a blister on the heel (resulting in a polyp).
As the chords remain dehydrated and continue to vibrate against each other, it creates
more and more vocal damage, and the singer is forced to compensate more and more for
it.

[17]

So what exactly are nodules and polyps? According to ASHA:

Vocal cord nodules are benign (noncancerous) growths on both vocal

cords that are caused by vocal abuse. Over time, repeated abuse of the
vocal cords results in soft, swollen spots on each vocal cord. These spots
develop into harder, callous-like growths called nodules. The nodules will
become larger and stiffer the longer the vocal abuse continues.

Polyps can take a number of forms. They are sometimes caused by vocal
abuse. Polyps appear on either one or both of the vocal cords. They appear
as a swelling or bump (like a nodule), a stalk-like growth, or a blister-like
lesion. Most polyps are larger than nodules and may be called by other
names, such as polypoid degeneration or Reinke's edema. The best way to
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think about the difference between nodules and polyps is to think of a

nodule as a callous and a polyp as a blister. [13]

What do nodules/polyps sound like? Signs of vocal damage appear in the

speaking/singing voice in ways like roughness in the voice, uneven vibrato (though that
could also be a sign of poor technique which will ultimately result in vocal damage),
heaviness, a decrease in pitch range, and/or pain in the throat. While going to an ENT
(Ears Nose Throat doctor) can be costly, one can do simple preliminary tests for vocal
damage such as attempting to sing a soft, smooth line in the middle of the voice, or
having a professional, reliable voice teacher examine their technique. If one or both
categories yield negative results, then it would be prudent to invest in a trip to the ENT.
Compounded with the industrys high usage of drugs and alcohol, taking TCAs along
with consuming those drying and damaging agents is a recipe for vocal damage. [13]
Referring back to the chart on page one, 6.7% of women in their lifetime will be
depressed, while only 4% of men will have the same illness. According to ASHA, women
ages 20-50 are the demographic which most commonly get nodes. [13] Taking these two
pieces of information into consideration, it seems as though female singers as a whole run
a significantly higher risk of contracting vocal damage than male singers.
If this is so, which voice type in specific runs the highest risk of all? It seems as
though the soprano, specifically singing high, dramatic soprano repertoire, would be at
the most risk for vocal damage while on TCAs. Because of the stretching of the folds to
hit higher pitches, the intense highs of a soprano singing dramatic coloratura repertoire
would put much more strain on a voice than the highs of a mezzo-soprano or a contralto.
Additionally, the pressure and weight of dramatic soprano repertoire would far exceed
that of a lyric or spinto soprano. The height coupled with the weight makes dramatic
coloratura rep pose the highest risk to sopranos suffering the dehydrating effects of
TCAs.
The point may be made that tenors, like sopranos, also stretch their vocal chords
to extremes to hit certain notes. Despite the similarities in vocal fold activity, the actual
frequency at which the folds vibrate put sopranos at a higher risk than these high tenors.
Mens vocal folds are on average 17-25mm and can vibrate anywhere from 90-500 Hz,
while womens vocal folds are 12.5-17.5 mm and can vibrate between 150-1000 Hz. [18]
[19] The speed and velocity at which the chords vibrate and rub together are very
different; vocal chords vibrating at higher speeds create more opportunity for dry,
dehydrated chords to rub together and cause inflammation, therefore putting female
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singers on TCAs at a higher risk compared to male singers on the same drugs, singing the
same amount.
Personally, I have taken a mixture of SSRIs and unusual antidepressants such as
Wellbutrin since I began college. That coupled with counseling and keeping busy with
school, music, and socializing has proved to be an effective treatment. Ive never
personally taken TCAs or experienced their effect on my voice firsthand, but I shied
away from the drug category after reading and hearing accounts from other singers.
Overall, a high number of those involved with or with a career in the arts and
entertainment industry will come to experience depression in their lifetime, if they are not
already depressed and drawn to the industry. During the duration of their career, they may
choose to treat their illness with medication. If that is the route they decide to go with
their depressive symptoms, it is advisable to avoid medication in the TCA category and
opt for the more popular option, SSRIs. While medication is useful and sometimes
necessary, it is always advisable for singers to seek out alternative medicine options,
therapy, counseling, or a mixture of the above.
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