When an anxiety disorder calls for a tricyclic, use whichever one the patient tolerates, and nortriptyline is classically one of the better tolerated; imipramine is the usual name only because it was the most researched. Tricyclics as a group still bring many more side effects: QTc danger at high doses, anticholinergic effects and heavy sedation.
Choosing a tricyclic
When anxiety calls for a tricyclic, imipramine is the usual pick only because it was the one researched most back in the day. Really, it is whichever tricyclic the patient tolerates, and we believe nortriptyline is classically one of the better tolerated.
“What's interesting is that that's just because that was the one that was researched the most back in the day. So, you know, you can go for imipramine. But really, it's whatever tricyclic is tolerated. I believe nortriptyline is usually... one of the classically better tolerated ones”
37:54Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025
Side effects and safety
Tricyclics as a group have many more side effects: they are dangerous at high doses because of QTc prolongation, cause anticholinergic effects such as dry mouth and urinary retention, and are very sedating.
“they have much more side effects. They are dangerous in high doses in QTC prolongation. They make people have anticholinergic side effects like dry mouth, urinary retention, and they're very sedating”
47:35Treating Depression: Practical Tips & Pearls for Anti-Depressant MedicationsJan 2025
From these episodes
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.