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sometimes used for chronic pain, migraine prevention Nortriptyline (Pamelor) Moderate weight gain, less than amitriptyline Still has metabolic risks Clinical use: Sometimes used for depression when SSRIs fail, neuropathic pain Imipramine (Tofranil) Moderate weight gain Associated with metabolic syndrome in longitudinal studies Clinical use: Occasionally for treatment-resistant depression, bedwetting in children Doxepin (Sinequan) Significant weight gain Very sedating Clinical use: Sometimes used for insomnia at very low doses (Silenor) Clomipramine (Anafranil) Moderate to significant weight gain Clinical use: OCD (FDA-approved), sometimes treatment-resistant depression Overall TCA assessment: TCAs as a class carry the highest metabolic risk

Independent Third-Party Testing Costs Money Sending every batch to an ISO/IEC 17025-accredited external laboratory for HPLC, mass spec, endotoxin, and sterility testing is a genuine line-item expense

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Continuum 24 , 11081136 (2018)