Antidepressants

• 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

• 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

• 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

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

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

• 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

• 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

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

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

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

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