Antidepressants

SSRIs

  • Citalopram (Celexa)
    • Available doses: 10 mg, 20 mg, 40 mg
    • Starting dose: 20 mg
    • Usual dose: 20 to 40 mg
  • Escitalopram (Cipralex; Lexapro):
    • Available doses: 5 mg, 10 mg, 20 mg
    • Starting dose: 10 mg
    • Usual dose: 10 to 20 mg
  • Fluoxetine (Prozac):
    • Available doses: 10 mg, 20 mg, 40 mg
    • Starting dose: 20 mg
    • Usual dose: 20 to 60 mg
  • Fluvoxamine (Luvox):
    • Available doses: 25 mg, 50 mg, 100 mg
    • Starting dose: 50 mg
    • Usual dose: 50 to 300 mg
  •  Paroxetine (Paxil):
    • Available doses: 10 mg, 20 mg, 30 m g, 40 mg
    • Starting dose: 20 mg
    • Usual dose: 20 to 40 mg
  •  Paroxetine CR
    • Available doses: 12.5 mg, 25 mg, 37.5 mg
    • Starting dose: 25 mg
    • Usual dose: 25 to 62.5 mg
  • Sertraline (Zoloft:
      • Available doses: 25 mg, 50 m g, 100 mg
      • Starting dose: 50 mg
      • Usual dose: 20 to 200 mg

SNRIs

  • Duloxetine (Cymbalta)
    • Available doses: 20 mg, 30 mg, 60 mg
    • Starting dose: 30 mg
    • Usual daily dose: 60 to 90 mg
  • Venlafaine (Effexor):
    • Available doses: 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg
    • Starting dose: 37.5 mg
    • Usual daily dose: 75 to 225 mg
  • Venlafaine XR (Effexor XR):
    • Available doses: 37.5 mg, 75 mg, 150 mg
    • Starting dose: 37.5 mg
    • Usual daily dose: 75 to 225 mg

Serotonin Modulators

  • Nefazodone (Serzone):
    • Available doses: 100 mg, 150 mg, 200 mg, 250 mg
    • Starting dose: 50 mg
    • Usual daily dose: 150 to 300 mg
  • Trazodone (Desyrel):
    • Available doses: 50 mg, 100 mg, 150 mg, 300 mg
    • Starting dose: 50 mg
    • Usual daily dose: 75 to 300 mg

Norepinephrine-Serotonin Modulators

  • Mirtazapine (remeron):
    • Available doses: 7.5 mg, 15 mg, 30 mg, 45 mg
    • Starting dose: 15 mg
    • Usual daily dose: 15 to 45 mg

TCAs

Tertiary amine tricyclics

  • Amitriptyline (Elavil):
    • Available doses: 10 mg, 25 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 mg to 300 mg
  • Clomipramine (Anafranil):
    • Available doses:25 mg, 50 mg, 75 mg
    • Starting dose: 25 mg
    • Usual daily dose: 100 to 250 mg
  • Doxepin (Sinequan):
    • Available doses: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 to 300 mg
  • Imipramine (Tofranil):
    • Available doses: 10 mg, 25 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 to 300 mg
  • Trimpiramine (Surmontil):
    • Available doses: 25 mg, 50 mg, 100 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 to 300 mg

Tertiary amine tricyclics

  • Desipramine (Normpramine):
    • Available doses: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
    • Starting dose: 25 to 50 mg
    • Usual daily dose: 100 to 300 mg
  • Nortiptyline (Pamelor, Aventyl):
    • Available doses: 10 mg, 25 mg, 50 mg, 75 mg
    • Starting dose: 25 mg
    • Usual daily dose: 50 to 150 mg
  • Protriptyline (vivactil):
    • Available doses: 5 mg, 10 mg
    • Starting dose: 10 mg
    • Usual daily dose: 15 to 60 mg

Tetracyclics

  • Amoxapine (Asendin):
    • Available doses: 25 mg, 50 mg, 100 mg, 150 mg
    • Starting dose: 50 mg
    • Usual daily dose: 100 to 400 mg
  • Maprotiline (Ludiomil):
    • Available doses: 25 mg, 50 mg, 75 mg
    • Starting dose: 50 mg
    • Usual daily dose: 100 to 225 mg

MAOi

  • Isocarboxzid (Marplan):
    • Available doses: 20 mg, 60 mg
    • Starting dose: 10 mg
    • Usual daily dose: 20 to 60 mg
  • Phenelzine (Nardil):
    • Available doses: 15 mg
    • Starting dose: 15 mg
    • Usual daily dose: 15 to 90 mg
  • Tranylcypromine (Parnate):
    • Available doses: 10 mg
    • Starting dose: 10 mg
    • Usual daily dose: 30 to 60 mg
  • Moclobemide
    • Available doses:100 mg, 150 mg
    • Starting dose: 150 mg
    • Usual daily dose: 300 to 600 mg

Guidelines for choosing antidepressant medications

Unipolar depression:

  • Choose on the basis of previous response, side effects and comorbid medical and psychotic conditions

Bipolar depression:

  • Lithium
  • Lamotrigine
  • Olanzapine-fluoxetine combination

Depression with psychotic features:

  • Antidepressants + Antipsychotics, or
  • ECT
  • Note: Avoid bupropion

Depression and panic disorder:

  • SSRI
  • TCA

Depression and seizure:

  • Note: Avoid Bupropion
  • Note: Avoid TCAs

Depression and Parkinson’s disease:

  • Bupropion

Depression and sexual dysfunction:

  • Bupropion
  • Mirtazapine

Depression and melancholic features:

  • TCA

Depression and atypical features: 

  • SSRIs
  • MAOi

Indications

Mirtazapine

  • Indications:
    • Major depression (15 mg/hs up to 45 mg)
    • Insomnia (15 mg/hs up to 45 mg)
    • Anxiety (15 mg/hs up to 45 mg)
  •  Side effects:
    • Weight gain
    • Sedation at initiation
    • Dizziness
    • Somnolence
    • Orthostatic hypotension
    • Hypertension
    • Peripheral edema due to peripheral vasodilation
  • Drug Interaction:
    • MAOIs
  • Overdose and toxicity:
    • Signs: Drowsiness, impaired memory, tachycardia
    • Treatment: Cardiac monitoring, gastric lavage, supportive measures

Trazodone

  • Indications:
    • Major Depression
    • Insomnia (50 to 100 mg/hs)
  • Side effects:
    • Orthostatic hypotension
    • Arrhythmia
    • Dry mouth
    • Blurred vision
    • Priapism

Venlafaxine

  • Major depression (start at 37.5 to 75 mg/day to 225 mg/day up to 375 mg/day)
  • Anxiety
  • Chronic pain

Duloxetine

  • Major depression (60 mg/day)
  • Pain related to diabetic neuropathy (up to 120 mg/day)
  • Fibromyalgia (120 mg/day)

Bupropion (Wellbutrin; Zyban)

  • Parkinson’s disease
  • Smoking cessation (150 mg SR bid or 300 mg XL once daily)
  • Gradual dose titration reduces initial anxiety and insomnia
  • Avoid in patients with seizure disorders and history of sever head trauma or brain tumor

Side effects

TCAs:

  • Sedation
  • Anticholinergic effects
    • Dry mouth, constipation, urinary retention, blurred vision, tachycardia, dilated pupils, delirium
    • Use with caution in prostatic hypertrophy, narrow-angle glaucoma or cognitive impairment
    • Reduce dose or switch to another category of antidepressants
  • Orthostasis
  • Quinidine like effects on cardiac conduction
  • Sedation
  • Arrhythmia
  • PR Prolongation
  • QRS prolongation
  • Should not be used in patient with heart block
  • lethal in overdose
  • Weight gain
  • Sexual dysfunction
  • Overdose:
    • Seizure, arrhythmia, hypotension, delirium, agitation, hallucination, seizure, HTN, dry mucous membranes, absent bowel sounds, tachycardia
    • Treatment: Atropine, cardiac monitoring, supportive care

SSRIs:

  • Minimal Sedation
  • Nausea
  • Loose bowel movements
  • Headache
  • Insomnia
  • Weight gain is rare
  • Sexual dysfunction
  • Jitteriness
  • Restlessness
  • Muscle tension
  • Tremor (can be managed by B-Blockers)
  • Akatisia (can be managed by B-Blockers)
  • Dystonia
  • Sedation
  • Exacerbation of Parkinson’s disease
  • Vivid dreams
  • Rash
  • Apathay:
    • Decreased motivation, increased passivity, lethargy
    • Management: Dose reduction; Stimulant medications; Olanzapine;
  • Reduced platelet aggregation
  • SIADH (lethargy, headache, hyponatremia, hyperosmotic urine,…)
  • Serotonin syndrome
    • Presents with: confusion, flushing, diaphoresis, tremor, myoclonic jerks…
    • Treatment: Cyproheptadine; Olanzapine
  • Discontinuation syndrome:
    • Dizziness, headache, nausea, paresthesia, diarrhea, insomnia, irritability.

Bupropion (Wellbutrin; Zyban):

  • Nausea
  • Headache
  • Insomnia
  • Anxiety or agitation
  • Seizure risk
  • Sweating
  • Gastrointestinal upset
  • Weight gain is none or little
  • Sexual dysfunction is rare
  • No seizure risk
  • Abuse of high doses: Hallucination, sinus tachycardia, seizure, loss of consciousness
  • No risk of cardiovascular or respiratory toxicity

SNRIs

  • Venlafaxine XR:
    • Nausea
    • loose bowel movements
    • headache
    • insomnia
    • hypertension (dose dependent)
    • Weight gain is rare
    • Sexual dysfunction
    • To avoid serotonin syndrome Venlafaxine should not be combined with MAOIs
    • Does not affect cardiac conduction
    • Does not reduce seizure threshold
    • No effect on cythochrom P450 enzymes
  • Duloxetine:
    • Nausea
    • loose bowel movements
    • headache
    • insomnia
    • hypertension (dose dependent)
    • Weight gain is rare
    • Some sexual dysfunction
    • Rare cases of increase in serum transaminase levels in the first 2 months of treatment that could result in ALT increases of three times the normal value. Should be used with caution in patients with alcohol use problem or liver diseases
    • Has been associated with Mydriasis, so should be used with caution in Narrow Angle Glaucoma patients
    • Does not affect cardiac conduction
    • Does not reduce seizure threshold
    • Duloxetine is a moderate inhibitor of cythochrom CYP 2D6 enzyme

Trazodone:

  • Sedation
  • Priapism
  • Dizziness
  • Orthostasis
  • Weight gain is rare
  • Sexual dysfunction is rare

Mirtazapine:

  • Anticholinergic effects
  • Orthostasis
  • HTN
  • Peripheral edema
  • Increased serum lipids
  • lethal in overdose
  • Weight gain
  • Sexual dysfunction is rare

MAOIs:

  • Insomnia
  • Orthostatic hypotension
  • Peripheral edema
  • lethal in overdose
  • Weight gain
  • Sexual dysfunction
  • Note:
    • Avoid foods with tyramine
    • Avoid in patients with CHF
    • Be aware of potential life threatening drug interactions

Pharmacological properties

TCAs:

  • Blockade of Muscarinic receptors
  • Blockade of Histamine H1 receptors
  • Blockade of a1-adrenergic receptors
  • Blockade of Norepinephrine (NEP) reuptake
  • Blockade of serotonin reuptake

SSRIs:

  • No impact on Muscarininc, H1, a1, NEP receptors
  • Only block the serotonin reuptake
  • Are much safer in overdose than TCAs
  • Unlikely to affect seizure threshold or cardiac conduction
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