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