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Antidepressant Drug Reference*

  1. Tricyclic Antidepressants (TCAs)
  2. Selective Serotonin Reptake Inhibitors (SSRIs)
  3. Monoamine Oxidase Inhibitors (MAOIs)
  4. Atypical Antidepressants

Tricyclic Antidepressants (TCAs)

*Drug Class/Generic Name (Proprietary Name)/Dosages  

Side Effects/Comments  

TRICYCLIC ANTIDEPRESSANTS (TCAs)

All TCAs can cause cardiac arrhythmias.

EKG at baseline to evaluate for preexisting cardiac conduction abnormalities. Therapeutic drug concentration ranges in plasma have been identified for all agents, but dosage adjustments should be based on a patient's clinical response and not solely on plasma concentrations. a

In responding patients, decrease daily dosages to the lowest effective amount needed to sustain a response. b TCAs can cause sexual dysfunction.

Treatment may be associated with weight gain. c

amitriptyline (Elavil)

Marked sedation; dizziness; headache; weight gain; anticholinergic effects; d orthostatic blood pressure (BP) changes (postural hypotension); may produce sexual dysfunction. Therapeutic plasma concentrations (parent drug + active metabolite) = 110-250 ng/mL.

initial: 10-25 mg as a single daily dose, preferably at bedtime

maintenance: 150-300 mg/day

clomipramine (Anafranil)

Anticholinergic effects; dizziness; drowsiness; headache; weight gain; orthostatic hypotension.

initial: 25 mg/day and gradually increase to 100 mg/day the first 2 weeks; may be given at bedtime

maintenance: 100-250 mg/day maximum

desipramine (Norpramin)

Mild sedation; increased appetite; nausea; minimal anticholinergic effects; d orthostatic BP changes. Therapeutic plasma concentrations = 125-300 ng/mL.

initial: 25-50 mg/day as a single daily dose, preferably at bedtime

maintenance: 100-300 mg/day as a single daily dose; In elderly patients, daily doses >150 mg are not recommended

doxepin (Sinequan)

Moderately to very sedating; dizziness; headache; weight gain; moderate anticholinergic effects; d postural hypotension. Optimal antidepressant effect is characteristically delayed by 2-3 weeks; however, onset of antianxiety effect is comparatively rapid. Therapeutic plasma concentrations (parent drug + active metabolite) = 100-200 ng/mL.

initial: 10-25 mg/day as a single daily dose, preferably at bedtime

maintenance: 75-300 mg/day as a single daily dose, preferably at bedtime

imipramine (Tofranil)

Moderately to very sedating; dizziness; headache; weight gain; moderate anticholinergic effects; d moderate-marked orthostatic BP changes; may produce sexual dysfunction (both genders). Therapeutic plasma concentrations (parent drug + active metabolite) = 200-350 ng/mL.

initial: 25-50 mg/day as a single daily dose, preferably at bedtime

maintenance: 75-200 mg/day as a single daily dose, preferably at bedtime

nortriptyline (Pamelor, Aventyl)

Mild-moderate sedation; constipation; nausea; increased appetite; mild-moderate anticholinergic effects; d the TCA least likely to produce postural hypotension. Therapeutic plasma concentrations = 50-150 ng/mL.

initial: 10-25 mg, 3-4 times daily

maintenance: 30-50 mg, 3 times daily, daily doses >150 mg are not recommended

B. Selective Serotonin Reptake Inhibitors (SSRIs)

*Drug Class/Generic Name (Proprietary Name)/Dosages  

Side Effects/Comments  

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

SSRIs have few anticholinergic and cardiovascular adverse effects. Life-threatening and fatal reactions have occurred in patients who receive SSRIs within 2 weeks of using monoamine oxidase inhibitor antidepressants. Sexual dysfunction has been reported to be associated with SSRI use. There is limited experience with long-term use.

citalopram (Celexa)

Ejaculation disorder; other sexual dysfunctions; insomnia; dry mouth; nausea; somnolence. In vitro studies indicated that CYP3A4 and CYP2C19 are the primary enzymes involved in the metabolism of citalopram. Citalopram is a relatively weak inhibitor of CYP2D6.

initial: 10 mg/day

maintenance: 10-40 mg/day

fluoxetine (Prozac)

Anxiety; nervousness; insomnia; anorexia; mild bradycardia; sinoatrial node slowing; weight loss; solar photosensitivity; hyponatremia; sexual dysfunction; may alter glycemic control in diabetic patients. Fluoxetine substantially inhibits CYP2D6 and may inhibit the clearance of other drugs metabolized by cytochrome P450 CYP2D6 isozymes. Fluoxetine probably inhibits CYP2C9/10, moderately inhibits CYP2C19, and mildly inhibits CYP3A4; fluoxetine metabolism is impaired in elderly patients.

initial: 10-20 mg/day

maintenance: 20-80 mg/day

escitalopram (Lexapro)

Nausea, vomiting, diarrhea, constipation, upset stomach, loss of appetite, dizziness, drowsiness, trouble sleeping, back pain, or dry mouth.

initial: 10 mg/day

maintenance: 10-20 mg/day

fluvoxamine (Luvox)

Nausea; sexual dysfunction; headache; nervousness; insomnia; drowsiness.

initial: 50 mg at bedtime, adjust in 50 mg increments at 4- to 7-day intervals

maintenance: 100-300 mg/day

paroxetine (Paxil)

Anxiety; nervousness; insomnia; mild weight loss; headache; solar photosensitivity; hyponatremia; sexual dysfunction. Paroxetine substantially inhibits and may interact with other drugs metabolized by cytochrome P450 CYP2D6 isozyme. Paroxetine metabolism is impaired in elderly patients.

initial: 10-20 mg/day

maintenance: 20-50 mg/day

sertraline (Zoloft)

Anxiety; nervousness; insomnia; mild weight loss; headache; solar photosensitivity; hyponatremia; sexual dysfunction. Produces mild inhibition of and may interact with drugs metabolized by cytochrome P450 CYP2D6 isozymes with little, if any, effect on CYP1A2, CYP2C9/10, CYP2C19, or CYP3A3/4.

initial: 25-50 mg/day

maintenance: 50-200 mg/day

 

C. Monoamine Oxidase Inhibitors (MAOIs)

*Drug Class/Generic Name (Proprietary Name)/Dosages  

Side Effects/Comments  

tranylcypromine (Parnate)

Orthostatic hypotension; drowsiness; hyperexcitability; headache. Low tyramine diet required.

initial: 10 mg twice daily, increase by 10 mg increments at 1- to 3-week intervals

maintenance: 10-40 mg/day

phenelzine (Nardil)

Orthostatic hypotension; drowsiness; hyperexcitability; headache. Low tyramine diet required.

initial: 15 mg 3 times a day

maintenance: 15-90 mg/day


D. Atypical Antidepressants

*Drug Class/Generic Name (Proprietary Name)/Dosages  

Side Effects/Comments  

ATYPICAL ANTIDEPRESSANTS

In general, serum drug concentrations do not correlate with antidepressant response.

Aplrazolam (Xanax)

Alprazolam (Xanax) and other benzodiazepines are used to treat anxiety disorders / panic attacked. Benzos (BZD) work to decrease abnormal excitement of the central nervous system. Side effets may include drowsiness, headache, irritability, dry mouth, increased salivation, ligh-headedness, tiredness, dizziness, difficulty concentrating, nausea, constipation, changes in sex drive, joint pain, difficulty uriniating, and weight changes. Contact your doctor immediately if you have shortness of breath, seizures, hallucinations.

initial: 0.25-0.5 mg 3 times daily

maintenance: dose may be increased every 3-4 days to a maximum dose of 4 mg dail (6 mg daily for preventing panic attacks)

bupropion (Wellbutrin, also approved for the treatment of smoking cessation as Zyban)

Initially activating dose-related seizure-inducing potential; contraindicated in patients with a history of seizure, in those with concomitant conditions predisposing to seizure, and in patients taking other drugs that lower seizure threshold. Mild-moderate sedation; mild-moderate anticholinergic effects; d mild orthostatic BP changes; agitation; insomnia; headache; confusion; dizziness; seizures; weight loss.

initial: 75 mg/day

maintenance: 200-450 mg/day not to exceed 150 mg/dose

trazodone (Desyrel)

Mild-moderate sedation; negligible anticholinergic effects; mild-moderate orthostatic BP changes, particularly in elderly patients; dizziness; headache; confusion; muscle tremors; may produce priapism; taking trazodone with food can decrease gastrointestinal upset. Therapeutic plasma concentrations = 800-1600 ng/mL.

initial: 50 mg/day

maintenance: 150-600 mg/day

nefazodone (Serzone)

Postural hypotension (although <TCAs); less sexual dysfunction than is reported with SSRIs. Headache; drowsiness; insomnia; agitation; confusion; nausea; tremor. Potential interaction with drugs metabolized by cytochrome P450 isozymes, CYP2D6 and CYP3A4. Check liver function tests at baseline and periodically during therapy. May cause fatal hepatotoxicity.

initial: 100 mg twice daily

maintenance: 300-600 mg/day

mirtazapine (Remeron)

A tetracyclic antidepressant. Mirtazapine elimination is decreased in elderly persons. Somnolence; dizziness; increased appetite and weight gain; constipation; hypertension; edema; confusion; increased nonfasting triglycerides and cholesterol; significantly increased hepatic ALT; orthostatic hypotension. When used concomitantly with drugs that reduce the seizure threshold (e.g., phenothiazines), mirtazapine may increase the risk of seizure.

initial: 7.5-15 mg/day

maintenance: 15-45 mg/day

venlafaxine (Effexor)

Dose-related sustained hypertension. Headache; dizziness; insomnia; nausea; constipation; abnormal ejaculation. Life-threatening and fatal reactions have occurred in patients who received venlafaxine within 2 weeks of using monoamine oxidase antidepressants.

initial: 75 mg/day

maintenance: 150-375 mg/day

duloxetine (Cymbalta)

Nausea, dry mouth, constipation, decreased appetite, fatigue, sleepiness, and increased sweating; decreased sexual drive or ability; urinary hesitation.

initial: 30 mg/day

maintenance: 30-60 mg/day

Psychostimulants

Psychostimulants may cause restlessness, agitation, insomnia, nightmares, psychosis, anorexia; and may exacerbate preexisting cardiac disease. Psychostimulants should be administered early in a patient's daily waking cycle. Psychostimulants are sometimes used adjuvantly to antagonize opioid analgesics' sedative effects.

dextroamphetamine (Dexedrine)

Drug tolerance, abuse, and dependence liability. Arrhythmia; nervousness; restlessness; insomnia. Contraindicated in patients with advanced arteriosclerosis, symptomatic cardiovascular disease, moderate-severe hypertension, and glaucoma.

 

initial: 2.5-5 mg/day

maintenance: 10-30 mg/day

methylphenidate (Ritalin, Methylin)

Drug tolerance, abuse, and dependence liability. Hypertension; may decrease the convulsive threshold in patients with a history of seizure disorders. Tachycardia; nervousness; insomnia; anorexia; drowsiness; dizziness.

initial: 2.5-10 mg/day

maintenance: 20-60 mg/day

dexmethylphenidate (Focalin)

Dry mouth, tremor or muscle spasms, nervousness, trouble sleeping, headache, drowsiness, nausea, insomnia, increased sweating, dizziness, lightheadedness, changes in sexual function.

initial: 10 mg/day

maintenance: 10-20 mg/day


 

*Consult complete prescribing information for appropriate administration schedules. This is not a substitute for your doctor's medical advice, nor is your doctor responsible for the content provided here. You should consult a medial professional if you have concerns about your health.

Notes:

a TCAs prolong cardiac conduction through His-Purkinje system similar to Type IA antiarrhythmic agents (e.g., quinidine). They are specifically contraindicated in patients with bundle-branch disease and second- or third-degree heart block. Their effects on conduction correlate with dosage and serum concentrations and for those agents with positive chronotropic and adrenergic-stimulating properties, TCAs can cause reentry arrhythmias. Persons at greatest risk are those with preexisting cardiac conduction defects and those who have taken an overdose.

b Plasma concentrations are most useful for guiding treatment in elderly patients who are (1) experiencing signs and symptoms of toxicity, (2) unresponsive to treatment, (3) suspected of being noncompliant with planned treatment, or (4) receiving other medications that may interact or otherwise alter antidepressant medication pharmacokinetics.

c TCAs and other antidepressants may cause sexual dysfunction characterized as decreased libido, penile erectile dysfunction, and decreased sensation during orgasm and ejaculation. Management consists of waiting for spontaneous resolution with continued therapy, decreasing the antidepressant dose, selecting an alternative antidepressant, or concomitant treatment with medications that treat the dysfunction (e.g., bethanechol for antidepressants with prominent anticholinergic effects).

d Common antimuscarinic or anticholinergic effects include dry mouth, blurred vision, constipation, and urinary retention. Although patients may eventually develop tolerance to these effects with repeated medication use, symptoms may not completely resolve until the drug is discontinued.

 

 
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