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ADMINISTRATION SCHEDULE FOR ANTIDEPRESSANTS *

 Anti-depressants

Therapeutic Dose Range (mg/day)

 Initial Suggested Dose

 Administration Schedule**

 

 

 

 

 

Selective Serotonin Reuptake Inhibitors (SSRIs)1

 

 

 

 

Citalopram

(Celexa)

 10 - 40

 20 mg in morning with food

 (10 mg in elderly and those

with comorbid panic disorder)

 Increase in 10 mg increments every 7 days as tolerated. Maintain 20 mg for

4 weeks before dose increase.

 Fluoxetine

 (Prozac)

 10 - 40

 20 mg in morning with food

 (10 mg in elderly and those

with comorbid panic disorder)

 Increase in 10 mg increments at intervals of 7 days. Maintain 20 mg for 4-6 weeks before dose increase. If significant side effects occur within 7 days, lower dose or change medication.

 

 

 

 

 Fluvoxamine

(Luvox)

 50 - 300

 100 mg in morning with food

 (50 mg in elderly and those

with comorbid panic disorder)

 Increase in 50 mg increments every 7 days as tolerated. Maintain 200 mg for at least 4 weeks before further dose increase.

 Paroxetine

(Paxil)

 10 - 50

 20 mg once daily, usually in morning with food

(10mg in elderly and those

with comorbid panic disorder)

 Increase in 10 mg increments at intervals of approximately 7 days up to a maximum of 40 mg/day. Maintain 20 mg for 4 weeks before dose increase.

 Sertraline

(Zoloft)

 50 - 150

 50 mg once daily, usually in morning with food

 Increase in 50 mg increments at intervals of 7 days as tolerated. Maintain

100 mg for 4 weeks before dose increase.

 Newer / Atypical Antidepressants

 Buproprion2

(Wellbutrin SR)

 150 - 450

 100 mg in morning

 Increase to 100 mg twice/day after 7 days. Then increase to 150 mg twice/day after 3 weeks and to 150 mg three times daily after 6 weeks.

 Mirtazapine

(Remeron)

 15 - 45

 15 mg at bedtime

(7.5 mg in elderly and those

with comorbid panic disorder)

Increase in 15 mg increments (7.5 mg in elderly) as tolerated. Maintain 30 mg for 4 weeks before further dose increase.

 Nefazodone3

(Serzone)

 200 - 600

 100 mg twice a day with food

 Increase in 100 mg increments at intervals of 7 days as tolerated. Administer in divided doses. Maintain 200 mg twice/day for 4 weeks before dose increase.

 Venlafaxine4

(Effexor XR)

 

75 - 300

 37.5 mg in morning with food

 Increase to 75 mg in morning after 1 week, 150 mg in the morning after 2 weeks, 225 mg in the morning after 4 weeks, and 300 mg in the morning after 6 weeks.

 

 

 

 

 


Tricyclic Antidepressants (TCAs)5

 Desipramine

(Norpramin)

 75 - 300

 50 mg at bedtime

 (25 mg in elderly)

 Increase in 25 mg increments every 7 days as tolerated to full therapeutic dose over period of several weeks. Once daily dosing at bedtime often minimizes side effects. Adequate trial considered to be 150 mg/day for at least 4 weeks.

 Doxepin

(Sinequan)

 

 75 - 300

 50 mg at bedtime

 25 mg in elderly)

 Increase in 25 mg increments every 7 days as tolerated to full therapeutic dose over period of several weeks. Once daily dosing at bedtime often minimizes side effects. Adequate trial considered to be 150 mg/day for at least 4 weeks.

 Imipramine

(Tofranil)

 75 - 300

 50 mg at bedtime

 Increase in 25 mg increments every 7 days as tolerated to full therapeutic dose over period of several weeks. Once daily dosing at bedtime often minimizes side effects. Adequate trial considered to be 150 mg/day for at least 4 weeks.

 Nortriptyline

(Pamelor)

 40 - 200

 25 mg

(10 mg in elderly)

 Increase in 10-25 mg increments every 7 days as tolerated to full therapeutic dose over period of several weeks. Only TCA with therapeutic window. Dosing too high may be ineffective. Suggest obtaining serum drug levels6 after 4 weeks if not effective.

 

 

 

GENERAL NOTES ABOUT PRESCRIBING ANTIDEPRESSANTS

** Doses should be increased as tolerated and as clinically indicated. Many patients will respond at doses below the maximum doses indicated in the therapeutic dose range.

1 SSRIs are recommended in depressed patients with comorbid panic or obsessive-compulsive disorder.

2 Avoid buproprion in patients at high risk for seizures such as patients with a history of seizures, significant central nervous system lesions, or head trauma. Also avoid buproprion in depressed patients with significant comorbid anxiety or bulimia.

3 Do not combine nefazodone (Serzone) with other drugs that are extensively metabolized by the P450 3A4 isoenzyme system such as terfenadine, astemizole and cisapride.

4 Venlafaxine (Effexor XR) can cause increases in blood pressure at higher doses.

5 Tricyclics (TCAs) have lower costs but may have more adverse side effects than SSRIs and other newer antidepressants. TCAs may be contraindicated in patients with certain physical comorbidities such as recent myocardial infarction, cardiac conduction defects, urinary retention, narrow angle glaucoma, orthostatic hypotension, renal failure and delirium / acute confusional states. Tertiary amine TCAs such as doxepin (Sinequan), imipramine (Tofranil) and amitriptyline (Elavil) are not recommended in older adults due to their unfavorable side effect profiles.

6 Target blood level is 50-150 ng/mL.