ANTIDEPRESSANTS

All dosing is for ADULTS unless otherwise specified. P = drugs with pediatric dosing recommendations.
PRICING INFO
References:
PREGNANCY SAFETY STUDIES


ADDING ANTIPSYCHOTIC IN RESISTANT MDD


TAMOXIFEN INTERACTION STUDIES


BUPROPION AND SMOKING CESSATION


LEXAPRO IN HEART FAILURE STUDY



Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Citalopram

(Celexa®)
Citalopram tablet
  • 10 mg
  • 20 mg
  • 40 mg
Depression
  • Starting: 20 mg a day
  • Maintenance: 20 - 40 mg a day
  • Max: 40 mg a day
  • Max dose of 20 mg a day recommended for patients > 60 years old, and patients with liver disease
  • For patients who are poor CYP2C19 metabolizers, and patients taking CYP2C19 inhibitors, the maximum daily dose is 20 mg. See CYP2C19 for more.
Citalopram
YES/$
  • May take without regard to food
  • SSRI
  • Inhibits serotonin reuptake by neurons
  • Depression
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 21%, P - 14%
  • Dry mouth - 20%, P - 14%
  • Somnolence - 18%, P - 10%
  • Insomnia - 15%, P - 14%
  • Increased sweating - 11%, P - 9%
  • Ejaculation disorder - 6%, P - 1%
  • Prolonged QT syndrome - citalopram should be stopped in patients with persistent QTc longer than 500 ms
  • Serotonin syndrome
  • Abnormal bleeding - through platelet inhibition
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Seizure - possible increase risk
  • Low sodium (hyponatremia) - may cause SIADH
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Poor CYP2C19 metabolizers - max dose 20 mg a day
  • Liver disease - maximum dose is 20 mg a day
  • Kidney disease
    • CrCl ≥ 30 ml/min: no dose adjustment necessary
    • CrCl < 30 ml/min: use caution
Drug Dosage form Dosage Generic/Price Other / Studies Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Escitalopram

(Lexapro®)
Escitalopram tablet
  • 5 mg
  • 10 mg
  • 20 mg
Depression

    Adults
    • Starting: 10 mg once daily
    • Maintenance: 10 - 20 mg once daily
    • Max: 20 mg once daily
    • Liver disease: 10 mg once daily
    • Elderly: 10 mg once daily
    • Increase dose after a minimum of one week
    Adolescents (12 - 17 years)
    • Starting: 10 mg once daily
    • Maintenance: 10 - 20 mg once daily
    • Max: 20 mg once daily
    • Increase dose after a minimum of three weeks
Generalized anxiety disorder

  • Starting: 10 mg once daily
  • Maintenance: 10 - 20 mg once daily
  • Max: 20 mg once daily
  • Liver disease: 10 mg once daily
  • Elderly: 10 mg once daily
  • Increase dose after a minimum of one week
Escitalopram
YES/$
Other
  • May take without regard to food

Studies
  • SSRI
  • Inhibits serotonin reuptake by neurons
  • Depression
  • Generalized anxiety disorder
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 15%, P - 7%
  • Insomnia - 9%, P - 4%
  • Ejaculation disorder (delay) - 9%, P - <1%
  • Diarrhea - 8%, P - 5%
  • Somnolence - 6%, P - 2%
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - recommended dose is 10 mg a day
  • Kidney disease
    • CrCl ≥ 30 ml/min: no dose adjustment necessary
    • CrCl < 30 ml/min: use caution
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Fluoxetine

(Prozac®)
(Prozac weekly™)
(Sarafem®)
Fluoxetine + olanzapine

(Symbyax®)
Fluoxetine capsule
  • 10 mg
  • 20 mg
  • 40 mg

Fluoxetine tablet
  • 10 mg
  • 20 mg
  • 60 mg

Prozac Weekly®
  • 90 mg capsule

Sarafem® tablet
  • 10 mg
  • 15 mg
  • 20 mg

Symbyax® capsule
Fluoxetine(mg):Olanzapine(mg)
  • 25:3
  • 25:6
  • 25:12
  • 50:6
  • 50:12

NOTE: see also olanzapine
Fluoxetine (Prozac®)

    Depression (Adults)
    • Starting: 20 mg once daily
    • Maintenance: 20 - 40 mg once daily
    • Max: 80 mg once daily
    Depression (Children and adolescents)
    • Starting: 10 - 20 mg once daily
    • Maintenance: 10 - 20 mg once daily
    • Max: 20 mg once daily
    • Lower weight children may only require 10 mg/day
    • In trials, children as young as 8 years old were included
    Obsessive compulsive disorder (Adults)
    • Starting: 20 mg once daily
    • Maintenance: 20 - 60 mg once daily
    • Max: 80 mg once daily
    Obsessive compulsive disorder (Adolescents and higher weight children)
    • Starting: 10 mg once daily for 2 weeks, then 20 mg once daily
    • Maintenance: 20 - 60 mg once daily
    • Max: 60 mg once daily
    • In trials, children as young as 7 years old were included
    Obsessive compulsive disorder (Lower weight children)
    • Starting: 10 mg once daily
    • Maintenance: 20 - 30 mg once daily
    • Max: 30 mg once daily
    • In trials, children as young as 7 years old were included
    Bulimia nervosa (Adults)
    • Target dose: 60 mg once daily
    • Max: 60 mg once daily
    • In trials, only the 60 mg dose was superior to placebo
    Panic disorder (Adults)
    • Starting: 10 mg once daily
    • Maintenance: 10 - 60 mg once daily
    • Max: 60 mg once daily

Prozac weekly®

    Depression
    • 90 mg once a week

Sarafem®

    Premenstrual dysphoric disorder
    • Continuous dosing: 20 mg once daily
    • Intermittent dosing: 20 mg once daily starting 14 days before menstruation through first full day of menses

Fluoxetine + olanzapine (Symbyax®)

    Depression associated with Bipolar 1 and
    Treatment resistant depression

    • Starting: 25/6 mg once daily in the evening
    • Maintenance: 25/6 mg - 50/18 mg once daily
    • Max: 75/18 mg once daily
    • NOTE: see also olanzapine

Prozac®
YES/$
Prozac weekly™
YES/$$-$$$
Sarafem­
NO/$$$$
Symbyax™
YES/$$$$
  • May take without regard to food
  • Switching from daily Prozac to Prozac weekly - start Prozac weekly 7 days after last daily dose
  • Full effect of medication may not be seen for 4 weeks
  • SSRI
  • Inhibits serotonin reuptake by neurons
Prozac®
  • Depression
  • Obsessive-Compulsive Disorder (OCD)
  • Bulimia Nervosa
  • Panic disorder
  • Premenstrual dysphoric disorder

Sarafem®
  • Premenstrual dysphoric disorder

Symbyax®
  • Depression associated with Bipolar 1
  • Treatment resistant depression
  • NOTE: see also olanzapine
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 22%, P - 9%
  • Headache - 21%, P - 19%
  • Insomnia - 19%, P - 10%
  • Nervousness - 13%, P - 8%
  • Fatigue - 11%, P - 6%
  • Diarrhea - 11%, P - 7%
  • Decreased appetite - 10%, P - 3%
  • Abnormal ejaculation - 7%, P - 1%
  • Thioridazine - DO NOT COMBINE
  • Pimozide (Orap®) - DO NOT COMBINE
  • MAO inhibitors - DO NOT COMBINE
  • Serotonergic drugs - may increase risk of serotonin syndrome
  • Drugs that prolong the QT interval - fluoxetine may prolong the QT interval. Use caution with other drugs that prolong the QT interval.
  • Anticoagulant/Antiplatelet meds - may increase bleeding risk
  • CYP2D6 substrates - fluoxetine is a strong CYP2D6 inhibitor
  • Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See for more.
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - use lower or less frequent dose. Manufacturer makes no specific dosage recommendations.
  • Kidney disease - no dose adjustment necessary
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Fluvoxamine

(Luvox®)
(Luvox® CR)
Luvox® tablet
  • 25 mg
  • 50 mg
  • 100 mg

Luvox CR® capsule
  • 100 mg
  • 150 mg
Obsessive compulsive disorder

    Luvox® (Adults)
    • Starting: 50 mg once daily at bedtime
    • Maintenance: 100 - 300 mg/day
    • Max: 300 mg/day
    • Doses > 100 mg should be given in 2 divided doses
    • Increase in increments of 50 mg/day every 4 - 7 days
    Luvox® (Children and adolescents 8 - 17 years)
    • Starting: 25 mg once daily at bedtime
    • Maintenance: 50 - 200 mg/day
    • Max: 300 mg/day
    • Doses > 50 mg should be given in 2 divided doses
    • Increase dose in increments of 25 mg/day every 4 - 7 days
    Luvox® CR
    • Starting: 100 mg once daily at bedtime
    • Maintenance: 100 - 300 mg once daily
    • Max: 300 mg once daily
    • Increase in increments of 50 mg/day every 7 days
Luvox®
YES/$
Luvox® CR
YES/$$$-$$$$
  • May take without regard to food
  • Because of the potential for drug interactions, fluvoxamine is not widely used
  • SSRI
  • Inhibits serotonin reuptake by neurons
  • Obsessive-Compulsive Disorder (OCD)
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 40%, P - 14%
  • Somnolence - 22%, P - 8%
  • Headache - 22%, P - 20%
  • Insomnia - 21%, P - 10%
  • Fatigue - 14%, P - 6%
  • Dry mouth - 14%, P - 10%
  • Nervousness - 12%, P - 5%
  • Dizziness - 11%, P - 6%
  • Diarrhea - 11%, P - 7%
  • Delayed ejaculation - 8%, P - 1%
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - clearance is decreased. Dose may need to be decreased. Manufacturer makes no specific dosage recommendations.
  • Kidney disease - kidney disease does not appear to affect clearance
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Paroxetine

(Paxil®)
(Paxil CR®)
(Brisdelle™)
(Pexeva®)
Paxil® (paroxetine HCL) tablet
  • 10 mg
  • 20 mg
  • 30 mg
  • 40 mg

Paxil CR® (paroxetine HCL) tablet
  • 12.5 mg
  • 25 mg
  • 37.5 mg

Pexeva® (paroxetine mesylate) tablet
  • 10 mg
  • 20 mg
  • 30 mg
  • 40 mg

Brisdelle™ (paroxetine mesylate)
  • 7.5 mg
Depression

    Paxil®, Pexeva®
    • Starting: 20 mg once daily
    • Maintenance: 20 - 50 mg once daily
    • Max: 50 mg once daily
    • Increase in increments of 10 mg/day every 7 days
    • Liver and kidney disease - initial dose 10 mg a day. Do not exceed 40 mg a day.
    Paxil CR®
    • Starting: 25 mg once daily
    • Maintenance: 25 - 62.5 mg once daily
    • Max: 62.5 mg once daily
    • Increase in increments of 12.5 mg/day every 7 days
    • Liver and kidney disease - initial dose 12.5 mg a day. Do not exceed 50 mg a day.

Obsessive compulsive disorder (OCD)

    Paxil®, Pexeva®
    • Starting: 20 mg once daily
    • Target: 40 mg once daily
    • Max: 60 mg once daily
    • Increase in increments of 10 mg/day every 7 days

Panic disorder

    Paxil®, Pexeva®
    • Starting: 10 mg once daily
    • Target: 40 mg once daily
    • Max: 60 mg once daily
    • Increase in increments of 10 mg/day every 7 days
    Paxil CR®
    • Starting: 12.5 mg once daily
    • Maintenance: 12.5 - 75 mg once daily
    • Max: 75 mg once daily
    • Increase in increments of 12.5 mg/day every 7 days

Social anxiety disorder

    Paxil®
    • Starting: 20 mg once daily
    • Maintenance: 20 - 60 mg once daily
    • Max: 60 mg once daily
    • Increase in increments of 10 mg/day every 7 days
    Paxil CR®
    • Starting: 12.5 mg once daily
    • Maintenance: 12.5 - 37.5 mg once daily
    • Max: 37.5 mg once daily
    • Increase in increments of 12.5 mg/day every 7 days

Generalized anxiety disorder

    Paxil®, Pexeva®
    • Starting: 20 mg once daily
    • Target: 20 once daily
    • Max: 50 mg once daily
    • Increase in increments of 10 mg/day every 7 days

Posttraumatic stress disorder

    Paxil®
    • Starting: 20 mg once daily
    • Target: 20 mg once daily
    • Max: 50 mg once daily
    • Increase in increments of 10 mg/day every 7 days

Premenstrual dysphoric disorder

    Paxil CR®
    • Continuous: 12.5 - 25 mg once daily
    • Intermittent: 12.5 - 25 mg once daily during the luteal phase (days 14 - 28 of the menstrual cycle with day 1 being the first day of menses)

Vasomotor symptoms associated with menopause

    Brisdelle™
    • 7.5 mg once daily at bedtime
Paxil®
YES/$
Paxil® CR
YES/$$-$$$
Pexeva®
NO/$$$$
Brisdelle™
NO/$$$-$$$$
All
  • May take without regard to food
Paxil® CR
  • Do not crush or chew tablet
  • SSRI
  • Inhibits serotonin reuptake by neurons
Paxil®
  • Depression
  • Panic disorder
  • Social anxiety disorder
  • Generalized anxiety disorder
  • Posttraumatic stress disorder (PTSD)
Paxil® CR
  • Depression
  • Panic disorder
  • Social anxiety disorder
  • Premenstrual dysphoric disorder
Pexeva®
  • Depression
  • Obsessive-Compulsive Disorder (OCD)
  • Panic disorder
  • Generalized anxiety disorder
Brisdelle™
  • Vasomotor symptoms in menopause
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 26%, P - 9%
  • Somnolence - 23%, P - 9%
  • Headache - 18%, P - 17%
  • Dry Mouth - 18%, P - 12%
  • Fatigue - 15%, P - 6%
  • Constipation - 14%, P - 9%
  • Dizziness - 13%, P - 6%
  • Insomnia - 13%, P - 6%
  • Ejaculatory delay - 13%, P - 0%
  • Diarrhea - 12%, P - 8%
  • Sweating - 11%, P - 2%
  • Other male sexual dysfunction - 10%, P - 0%
  • MAO inhibitors - DO NOT COMBINE
  • Pimozide (Orap®) - DO NOT COMBINE
  • Thioridazine - DO NOT COMBINE
  • Cimetidine (Tagamet®) - may increase paroxetine levels
  • Risperidone (Risperdal®) - may increase risperidone levels
  • Tricyclic antidepressants (TCA) - may increase TCA levels
  • Fosamprenavir/Ritonavir - may decrease paroxetine levels
  • Drugs that prolong the QT interval
  • Serotonergic drugs - may increase risk of serotonin syndrome
  • Anticoagulant/Antiplatelet meds - may increase bleeding risk
  • CYP2D6 substrates - paroxetine is a strong CYP2D6 inhibitor
  • Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See for more.
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease
    • Paxil, Pexeva
      • Severe (Child-Pugh C): starting - 10 mg/day; do not exceed 40 mg/day
    • Paxil CR
      • Severe (Child-Pugh C): starting - 12.5 mg/day; do not exceed 50 mg/day
    • Brisdelle
      • No dose adjustment necessary
  • Kidney disease
    • Paxil, Pexeva
      • CrCl 30 - 60 ml/min: paroxetine levels increase 2-fold; use caution
      • CrCl < 30 ml/min: starting - 10 mg/day; do not exceed 40 mg/day
    • Paxil CR
      • CrCl 30 - 60 ml/min: paroxetine levels increase 2-fold; use caution
      • CrCl < 30 ml/min: starting - 12.5 mg/day; do not exceed 50 mg/day
    • Brisdelle
      • No dose adjustment necessary
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Sertraline

(Zoloft®)
Zoloft®
  • 25 mg
  • 50 mg
  • 100 mg
Depression
  • Starting: 50 mg once daily
  • Maintenance: 50 - 200 mg once daily
  • Max: 200 mg once daily
  • Increase dose at intervals of ≥ 1 week

Obsessive compulsive disorder
    Adults
    • Starting: 50 mg once daily
    • Maintenance: 50 - 200 mg once daily
    • Max: 200 mg once daily
    • Increase dose at intervals of ≥ 1 week
    Children and adolescents
    • Starting (6 - 12 years old): 25 mg once daily
    • Starting (13 - 17 years old): 50 mg once daily
    • Maintenance: 50 - 200 mg once daily
    • Max: 200 mg once daily
    • Increase dose at intervals of ≥ 1 week

Panic disorder,
Posttraumatic stress disorder (PTSD),
Social anxiety disorder
  • Starting: 25 mg once daily
  • Maintenance: 50 - 200 mg once daily
  • Max: 200 mg a day
  • Increase dose at intervals of ≥ 1 week

Premenstrual dysphoric disorder
  • Continuous: 50 - 150 mg once daily
  • Intermittent: 50 - 100 mg once daily during the luteal phase (days 14 - 28 of the menstrual cycle with day 1 being the first day of menses)
  • Increase dose at the onset of each new cycle
  • For 100 mg/day intermittent dosing, use 50 mg/day for first 3 days of each new cycle

Zoloft®
YES/$
  • May take without regard to food
  • Selective Serotonin Reuptake Inhibitor (SSRI)
  • Inhibits serotonin reuptake by neurons
  • Depression
  • Obsessive-Compulsive Disorder (OCD)
  • Panic disorder
  • Posttraumatic Stress Disorder (PTSD)
  • Premenstrual Dysphoric Disorder
  • Social Anxiety Disorder
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 25%, P - 11%
  • Headache - 25%, P - 23%
  • Insomnia - 21%, P - 11%
  • Diarrhea - 20%, P - 10%
  • Ejaculation failure - 14%, P - 1%
  • Dry Mouth - 14%, P - 8%
  • Somnolence - 13%, P - 7%
  • Dizziness - 12%, P - 7%
  • Fatigue - 12%, P - 7%
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - clearance is decreased. Use caution. Decrease dose or frequency.
  • Kidney disease - no dose adjustment necessary
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Desvenlafaxine Succinate

(Pristiq®)

Desvenlafaxine

(Khedezla™)
Pristiq®
extended-release tablet

  • 25 mg
  • 50 mg
  • 100 mg

Khedezla™
extended-release tablet

  • 50 mg
  • 100 mg
Depression

    Pristiq®, Khedezla™
    • Starting: 50 mg once daily
    • Maintenance: 50 - 400 mg once daily
    • Max: 400 mg once daily
    • Pristiq and Khedezla are not considered therapeutically equivalent and cannot be substituted for each other
Pristiq®
YES/$$-$$$

Khedezla™
YES/$$$-$$$$
Pristiq®, Khedezla™
  • May take without regard to food
  • Take at approximately the same time every day
  • Do not cut, crush, or chew tablet
  • In trials, no additional benefit was seen at doses greater than 50 mg a day
  • Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
  • Inhibits serotonin and norepinephrine reuptake by neurons
  • Depression
NOTE: P = % of patients on placebo who reported side effect. Side effects presented here are for 100 mg/day dosing.
  • Nausea - 26%, P - 10%
  • Dry Mouth - 17%, P - 9%
  • Insomnia - 12%, P - 6%
  • Sweating - 11%, P - 4%
  • Dizziness - 10%, P - 5%
  • Constipation - 9%, P - 4%
  • Ejaculation delay - 5%, P - < 1%
  • Erectile dysfunction - 6%, P - 1%
  • Orthostatic hypotension - 8% of patients ≥ 65 years
  • Elevated blood pressure - desvenlafaxine may cause an increase in blood pressure. Effect is typically small. Average SBP increase 2 - 4 mmHg.
  • Elevated cholesterol - desvenlafaxine may raise cholesterol levels (4 - 10% of patients)
  • MAO inhibitors - DO NOT COMBINE
  • Serotonergic drugs - may increase risk of serotonin syndrome
  • Anticoagulant/Antiplatelet meds - may increase bleeding risk
  • CYP2D6 substrates - desvenlafaxine is a weak CYP2D6 inhibitor. When taking desvenlafaxine 400 mg a day, may need to half dose of sensitive CYP2D6 substrates.
  • CYP3A4 strong inhibitors - desvenlafaxine is a minor substrate of CYP3A4. Strong CYP3A4 inhibitors may increase desvenlafaxine levels.
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Hypertension - may raise blood pressure
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease
    • Moderate-severe disease (Child-Pugh B and C): recommended dose is 50 mg a day; do not exceed 100 mg a day
  • Kidney disease
    • CrCl 30 - 50 ml/min: max dose is 50 mg a day
    • CrCl < 30 ml/min: max dose is 50 mg every other day
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Duloxetine

(Cymbalta®)
Cymbalta® capsule
  • 20 mg
  • 30 mg
  • 60 mg
Depression
  • Starting: 30 - 60 mg a day
  • Maintenance: 40 - 60 mg/day
  • Max: 120 mg/day
  • May be given once daily or in two divided doses

Generalized anxiety disorder
    Adults
    • Starting: 30 - 60 mg once daily
    • Maintenance: 60 - 120 mg once daily
    • Max: 120 mg once daily
    • For elderly patients, starting dose should be 30 mg once daily. Increase to 60 mg once daily after 2 weeks.
    Children and adolescents (7 - 17 years)
    • Starting: 30 mg once daily
    • Maintenance: 30 - 60 mg once daily
    • Max: 120 mg/day
    • Increase dose in increments of 30 mg/day at intervals of ≥ 2 weeks

Diabetic peripheral neuropathy
  • Starting: 30 - 60 mg once daily
  • Target: 60 mg once daily
  • Max: 60 mg once daily

Fibromyalgia
  • Starting: 30 - 60 mg once daily
  • Target: 60 mg once daily
  • Max: 60 mg once daily

Chronic musculoskeletal pain
  • Starting: 30 - 60 mg once daily
  • Target: 60 mg once daily
  • Max: 60 mg once daily
Cymbalta®
YES/$
  • May take without regard to food

  • Do not open, crush, or chew capsule

  • In most studies, doses > 60 mg a day have not shown additional benefit
  • Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
  • Inhibits serotonin and norepinephrine reuptake by neurons
  • Depression
  • Generalized anxiety disorder
  • Diabetic peripheral neuropathy
  • Fibromyalgia
  • Chronic musculoskeletal pain
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 23%, P - 8%
  • Dry Mouth - 14%, P - 6%
  • Headache - 14%, P - 14%
  • Constipation - 9%, P - 4%
  • Diarrhea - 9%, P - 6%
  • Fatigue - 9%, P - 5%
  • Somnolence - 9%, P - 3%
  • Insomnia - 9%, P - 5%
  • Erectile dysfunction - 4%, P - 1%
  • Ejaculation delay - 2%, P - 1%
  • Elevated liver enzymes (> 3X upper limit of normal) - 1.25%, P - 0.45%
  • Elevated blood pressure - duloxetine may cause an increase in blood pressure. Effect is typically small. Average SBP increase 1 - 2 mmHg at typical dosing.
  • Orthostatic hypotension - may occur in some patients
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Hypertension - may raise blood pressure
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Decreased gastric motility - may affect absorption
  • Low sodium (hyponatremia) - may cause SIADH
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - do not use in patients with significant liver disease
  • Kidney disease
    • CrCl ≥ 30 ml/min: no dose adjustment necessary
    • CrCl < 30 ml/min: DO NOT USE
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Levomilnacipran

(Fetzima™)
Fetzima™
extended-release capsule

  • 20 mg
  • 40 mg
  • 80 mg
  • 120 mg

Titration pack:
20 mg capsule X 2
40 mg capsule X 26
Depression
  • Starting: 20 mg once daily for 2 days, then 40 mg once daily
  • Maintenance: 40 - 120 mg once daily
  • Max: 120 mg once daily
  • Increase in increments of 40 mg/day at intervals of ≥ 2 days

Dosing in kidney disease
  • CrCl ≥ 60 ml/min: no dose adjustment necessary
  • CrCl 30 - 59 ml/min: do not exceed 80 mg a day
  • CrCl 15 - 29 ml/min: do not exceed 40 mg/day
  • CrCl < 15 ml/min: not recommended

Dosing with strong CYP3A4 inhibitors
  • Do not exceed 80 mg a day
  • See CYP3A4 for more
Fetzima™
NO/$$$$
  • May take without regard to food
  • Do not open, chew, or crush capsule
  • Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
  • Inhibits serotonin and norepinephrine reuptake by neurons
  • Depression
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 17%, P - 6%
  • Constipation - 9%, P - 3%
  • Excessive sweating - 9%, P - 2%
  • Erectile dysfunction - 6%, P - 1%
  • Rapid heart beat - 6%, P - 2%
  • Urinary hesitancy/retention - 5%, P - 0%
  • Ejaculation disorder - 5%, P - <1%
  • Vomiting - 5%, P - 1%
  • Palpitations - 5%, P - 1%
  • Testicular pain - 4%, P - <1%
  • Hot flush - 3%, P - 1%
  • Orthostatic hypotension - 3%, P - 1%
  • Decreased appetite - 3%, P - 1%
  • Elevated blood pressure - levomilnacipran may cause an increase in blood pressure. Effect is typically small. Average SBP increase 3 - 4 mmHg, average DBP increase 3 mmHg.
  • Increase in heart rate - levomilnacipran may cause an increase in heart rate. Average increase of 7-9 bpm in studies
  • MAO inhibitors - DO NOT COMBINE
  • Alcohol - alcohol may accelerate drug release from the levomilnacipran capsule. It is recommended that it not be taken with alcohol.
  • CYP3A4 strong inhibitors - levomilnacipran is a CYP3A4 sensitive substrate. The dose of levomilnacipran should not exceed 80 mg a day when taken with CYP3A4 strong inhibitors
  • Serotonergic drugs - may increase risk of serotonin syndrome
  • Anticoagulant/Antiplatelet meds - may increase bleeding risk
  • Uncontrolled narrow-angle glaucoma - DO NOT USE
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Urinary retention (e.g. BPH) - levomilnacipran may worsen urinary retention in certain conditions
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Hypertension - may raise blood pressure
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - no dose adjustment necessary
  • Kidney disease
    • CrCl ≥ 60 ml/min: no dose adjustment necessary
    • CrCl 30 - 59 ml/min: do not exceed 80 mg a day
    • CrCl 15 - 29 ml/min: do not exceed 40 mg/day
    • CrCl < 15 ml/min: not recommended
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Venlafaxine

(Effexor®)
(Effexor XR®)
Effexor® tablet
  • 25 mg
  • 37.5 mg
  • 50 mg
  • 75 mg
  • 100 mg

Effexor XR®
extended-release capsule

  • 37.5 mg
  • 75 mg
  • 150 mg

Effexor XR®
extended-release tablet

  • 37.5 mg
  • 75 mg
  • 150 mg
  • 225 mg
Depression

    Effexor®
    • Starting: 75 mg a day
    • Maintenance: 75 - 225 mg a day
    • Max: 375 mg a day
    • Give in 2 to 3 divided doses
    • Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days
    • Doses higher than 225 mg a day have not been extensively studied
    Effexor XR®
    • Starting: 37.5 - 75 mg once daily
    • Maintenance: 75 - 225 mg once daily
    • Max: 225 mg once daily
    • Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days

Generalized anxiety disorder

    Effexor XR®
    • Starting: 37.5 - 75 mg once daily
    • Maintenance: 75 - 225 mg once daily
    • Max: 225 mg once daily
    • Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days

Social anxiety disorder

    Effexor XR®
    • Target: 75 mg once daily
    • There is no evidence that higher doses are beneficial

Panic disorder

    Effexor XR®
    • Starting: 37.5 once daily
    • Maintenance: 75 - 225 mg once daily
    • Max: 225 mg once daily
    • Increase dose in increments of up to 75 mg/day at intervals of ≥ 7 days

Migraine prevention (off-label)

    Effexor XR®
    • 75 - 150 mg/day

Diabetic neuropathy (off-label)

Effexor®
YES/$
Effexor XR®
YES/
capsule - $
tablet - $$-$$$
Effexor®
  • Take with food to help reduce nausea
  • May cause false-positive urine drug tests for phencyclidine (PCP) and amphetamines

Effexor XR®
  • Take with food to help reduce nausea
  • May cause false-positive urine drug tests for phencyclidine (PCP) and amphetamines
  • Capsules may be opened and sprinkled on applesauce. Do not chew contents.
  • Do not crush, cut, or chew tablet

Switching brands
  • When switching between Effexor® and Effexor XR®, keep total daily dose the same
  • Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
  • Inhibits serotonin and norepinephrine reuptake by neurons
  • Weak dopamine reuptake inhibitor
  • Depression
  • Generalized anxiety disorder
  • Social anxiety disorder
  • Panic disorder
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 35%, P - 12%
  • Dizziness - 16%, P - 11%
  • Dry Mouth - 16%, P - 6%
  • Insomnia - 15%, P - 10%
  • Somnolence - 14%, P - 8%
  • Fatigue - 12%, P - 8%
  • Ejaculation delay/abnormal - 11%, P - < 1%
  • Constipation - 10%, P - 4%
  • Sweating - 10%, P - 3%
  • Elevated blood pressure - venlafaxine may cause an increase in blood pressure. The effect increases with higher doses.
  • Elevated cholesterol - venlafaxine may raise cholesterol levels (5.3% of patients)
  • MAO inhibitors - DO NOT COMBINE
  • Cimetidine (Tagamet®) - may increase venlafaxine levels
  • Haloperidol (Haldol®) - may increase haloperidol levels
  • Desipramine - may increase desipramine levels
  • Metoprolol - may increase metoprolol levels
  • Risperidone (Risperdal®) - may increase risperidone levels
  • Indinavir (Crixivan®) - may decrease indinavir levels
  • Drugs that prolong the QT interval
  • Serotonergic drugs - may increase risk of serotonin syndrome
  • Anticoagulant/Antiplatelet meds - may increase bleeding risk
  • CYP2D6 inhibitors and substrates - venlafaxine is a CYP2D6 sensitive substrate and CYP2D6 weak inhibitor
  • CYP3A4 inhibitors - may increase venlafaxine levels
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Hypertension - may raise blood pressure
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease
    • Effexor, Effexor XR
      • Mild-moderate disease (Child-Pugh A/B): reduce dose by 50%
      • Severe (Child-Pugh C): reduce dose by 50% or more
  • Kidney disease
    • Effexor
      • CrCl 30 - 90 ml/min: reduce dose by 25%
      • CrCl < 30 ml/min: reduce dose by 50%
    • Effexor XR
      • CrCl 30 - 90 ml/min: reduce dose by 25% - 50%
      • CrCl < 30 ml/min: reduce dose by 50% or more
Drug Dosage form Dosage Generic/Price Other / Studies Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Bupropion

(Wellbutrin®)
(Wellbutrin SR®)
(Wellbutrin XL®)
(Zyban®)
(Aplenzin®)
(Forfivo XL™)
(Contrave®)
Wellbutrin® tablet
  • 75 mg
  • 100 mg

Wellbutrin SR® tablet
  • 100 mg
  • 150 mg
  • 200 mg

Wellbutrin XL® tablet
  • 150 mg
  • 300 mg

Forfivo XL™ tablet
  • 450 mg

Zyban® tablet
  • 150 mg

Aplenzin®
(Bupropion hydrobromide) tablet

  • 174 mg
  • 348 mg
  • 522 mg

Contrave®
(naltrexone + bupropion)
see Contrave®
Depression

    Wellbutrin®
    • Starting: 100 mg twice a day for 3 days
    • Maintenance: 100 mg three times a day
    • Max: 450 mg a day
    Wellbutrin SR®
    • Starting: 150 mg once a day for 3 days
    • Maintenance: 150 mg twice a day
    • Max: 200 mg twice a day
    Wellbutrin XL®
    • Starting: 150 mg once daily
    • Maintenance: 300 mg once daily
    • Max: 450 mg once daily
    • Increase dose at intervals ≥ 4 days
    Aplenzin®
    • Starting: 174 mg once daily for 4 days
    • Maintenance: 348 mg once daily
    • Max: 522 mg once daily
    • Aplenzin-Wellbutrin XL equivalence:
      174 mg = 150 mg, 348 mg = 300 mg, 522 = 450 mg
    Forfivo XL™
    • Starting: use another form of bupropion to initiate therapy
    • Maintenance: 450 mg once daily
    • Max: 450 mg once daily

Seasonal affective disorder

    Wellbutrin XL®
    • Starting: 150 mg once daily
    • Target: 300 mg once daily
    • Max: 300 mg once daily
    • Increase dose at intervals ≥ 7 days
    Aplenzin®
    • Starting: 174mg once daily
    • Target: 348mg once daily
    • Max: 348mg once daily
    • Increase dose at intervals ≥ 7 days
    • Aplenzin-Wellbutrin XL equivalence:
      174mg = 150 mg, 348mg = 300 mg, 522 = 450 mg

Smoking cessation

    Zyban®
    • Starting: 150 mg once daily for 3 days
    • Maintenance: 150 mg twice a day
    • Max: 150 mg twice a day

Weight loss

    Contrave® (naltrexone + bupropion)
Wellbutrin®
YES/$
Wellbutrin SR®
YES/$
Wellbutrin XL®
YES/$
Forfivo XL™
NO/$$$$
Aplenzin®
NO/$$$$
Zyban®
YES/$-$$
Other
    All
    • May take without regard to food
    • Do not crush, cut, or chew tablets
    • May cause false-positive urine drug tests for amphetamines
    Switching brands
    • When switching between Wellbutrin®, Wellbutrin SR®, and Wellbutrin XL® - keep total daily dose the same

Studies
  • Norepinephrine-Dopamine Reuptake Inhibitor
  • Inhibits norepinephrine and dopamine reuptake by neurons
  • Depression
  • Seasonal affective disorder
  • Smoking cessation
NOTE: P = % of patients on placebo who reported side effect
  • Agitation - 32%, P - 22%
  • Dry mouth - 28%, P - 18%
  • Constipation - 26%, P - 17%
  • Headache - 26%, P - 22%
  • Nausea - 23%, P - 19%
  • Excessive sweating - 22%, P - 15%
  • Dizziness - 22%, P - 16%
  • Tremor - 21%, P - 8%
  • Insomnia - 19%, P - 16%
  • Blurred vision - 15%, P - 10%
  • Rapid heart beat - 11%, P - 9%
  • Increased blood pressure - may increase blood pressure. Incidence is unknown.
  • MAO inhibitors - DO NOT COMBINE
  • CYP2B6 inhibitors and inducers - bupropion is a CYP2B6 sensitive substrate
  • CYP2D6 substrates - bupropion is a CYP2D6 strong inhibitor
  • OCT2 substrates - bupropion is an OCT2 inhibitor
  • Amantadine - may increase side effects
  • Clopidogrel (Plavix®) - clopidogrel is a CYP2B6 inhibitor and may raise bupropion levels. Bupropion doses may need to be decreased when taken with clopidogrel.
  • Digoxin - bupropion may decrease digoxin levels. Monitor digoxin levels when taking together.
  • Levodopa (Sinemet®) - may increase side effects
  • Drugs that increase dopaminergic or noradrenergic activity - may increase risk of hypertension
  • Ritonavir, Lopinavir, and Efavirenz - ritonavir, lopinavir, and efavirenz are CYP2B6 inducers and may lower bupropion levels to subtherapeutic levels
  • Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See for more.
  • Seizure disorder - DO NOT USE. Bupropion carries the highest seizure risk of all the antidepressants.
  • Bulimia or anorexia nervosa - DO NOT USE. These patients have higher risk of seizure.
  • Alcohol/benzodiazepine/barbiturate withdrawal - DO NOT USE. These patients have higher risk of seizure.
  • Antiepileptic drug withdrawal - DO NOT USE. These patients have higher risk of seizure.
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease
    • Wellbutrin
      • Mild (Child-Pugh A): consider dose/frequency reduction
      • Moderate-severe (Child-Pugh B/C): do not exceed 75 mg a day
    • Wellbutrin SR
      • Mild (Child-Pugh A): consider dose/frequency reduction
      • Moderate-severe (Child-Pugh B/C): max dose is 100 mg a day or 150 mg every other day
    • Wellbutrin XL, Zyban
      • Mild (Child-Pugh A): consider dose/frequency reduction
      • Moderate-severe (Child-Pugh B/C): max dose is 150 mg every other day
    • Aplenzin
      • Severe (Child-Pugh C): max dose is 174mg every other day
    • Forfivo XL
      • Liver disease not recommended since only one dose
  • Kidney disease
    • CrCl < 90 ml/min: consider dose/frequency reduction
    • Forfivo XL is not recommended since only one dose
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Amitriptyline

(Elavil®)
Amitriptyline tablet
  • 10 mg
  • 25 mg
  • 50 mg
  • 75 mg
  • 100 mg
  • 150 mg
Depression
  • Starting: 25- 50 mg once daily
  • Maintenance: 50 - 100 mg once daily
  • Max: 150 mg once daily

Migraine prevention (off-label)

  • 25 - 150 mg/day

Diabetic neuropathy (off-label)

Amitriptyline
YES/$
  • May take without regard to food
  • Tricyclic antidepressant
  • Inhibits norepinephrine and serotonin reuptake by neurons
  • Depression
NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more)
  • Dry mouth - > 50% of patients in some trials
  • Drowsiness - common
  • Blurred vision
  • Constipation
  • Urinary retention
  • Postural hypotension
  • Seizure - may increase risk
  • Serotonin syndrome
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Urinary retention - may worsen
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abnormal bleeding - through platelet inhibition
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - use caution
  • Kidney disease - use caution
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Clomipramine

(Anafranil™)
Clomipramine capsule
  • 25 mg
  • 50 mg
  • 75 mg
Obsessive compulsive disorder

  • Starting: 25 mg a day
  • Maintenance: 100 mg a day
  • Max: 250 mg a day
  • When initiating, increase to 100 mg a day over the course of 2 weeks
  • May be given in divided doses to decrease gastrointestinal side effects
Anafranil™
YES/$$$$
  • Take with food to limit GI side effects
  • Gradually increase dose. May give twice a day when initiating to limit side effects.
  • Tricyclic antidepressant
  • Inhibits norepinephrine and serotonin reuptake by neurons
  • Obsessive-compulsive disorder (OCD)
NOTE: P = % of patients on placebo who reported side effect
  • Dry mouth - 84%, P - 17%
  • Somnolence - 54%, P - 16%
  • Tremor - 54%, P - 2%
  • Dizziness - 54%, P - 14%
  • Headache - 52%, P - 41%
  • Constipation - 47%, P - 11%
  • Ejaculation failure - 42%, P - 2%
  • Nausea - 33%, P - 14%
  • Increased sweating - 29%, P - 3%
  • Insomnia - 25%, P - 15%
  • Libido change - 21%, P - 3%
  • Impotence - 20%, P - 3%
  • Weight gain - 18%, P - 1%
  • Abnormal vision - 18%, P - 4%
  • Nervousness - 18%, P - 2%
  • Urinary retention - 14%, P - 2%
  • Diarrhea - 13%, P - 9%
  • Myalgia - 13%, P - 9%
  • Muscle twitching - 13%, P - 0%
  • Increased appetite - 11%, P - 2%
  • Orthostatic hypotension
  • Elevated liver enzymes - 1-3% of patients
  • Seizure - may increase risk
  • Serotonin syndrome
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Urinary retention - may worsen
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abnormal bleeding - through platelet inhibition
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - use caution
  • Kidney disease - use caution
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Desipramine

(Norpramin®)
Desipramine tablet
  • 10 mg
  • 25 mg
  • 50 mg
  • 75 mg
  • 100 mg
  • 150 mg
Depression

  • Starting: 50 mg/day
  • Maintenance: 100 - 200 mg/day
  • Max: 300 mg/day
  • May be given once daily or in divided doses
Desipramine
YES/$$-$$$
  • May take without regard to food
  • Tricyclic antidepressant
  • Inhibits norepinephrine and serotonin reuptake by neurons
  • Depression
NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more)
  • Dry mouth - > 50% of patients in some trials
  • Drowsiness - common
  • Blurred vision
  • Constipation
  • Urinary retention
  • Postural hypotension
  • Seizure - may increase risk
  • Serotonin syndrome
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Urinary retention - may worsen
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abnormal bleeding - through platelet inhibition
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - use caution
  • Kidney disease - use caution
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Imipramine

(Tofranil™)
(Tofranil-PM™)
Tofranil™ tablet
  • 10 mg
  • 25 mg
  • 50 mg

Tofranil-PM™ capsule
  • 75 mg
  • 100 mg
  • 125 mg
  • 150 mg
Depression

    Tofranil™
    • Starting: 75 mg a day
    • Maintenance: 50 - 150 mg a day
    • Max: 200 mg a day
    • May be given once daily or in divided doses
    Tofranil PM™
    • Starting: 75 mg a day
    • Maintenance: 75 - 150 mg a day
    • Max: 200 mg a day
    • May be given once daily or in divided doses

Childhood enuresis (≥ 6 years old)

    Tofranil™
    • Starting: 25 mg one hour before bedtime
    • Maintenance:
      (6-11 years) 25 - 50 mg at night
      (≥ 12 years) 25 - 75 mg at night
    • Max: 2.5 mg/kg/day or 75 mg a day, whichever is less
    • For early bedwetters, a divided dose of 25 mg given midafternoon and repeated at bedtime may be more effective
Tofranil™
YES/$
Tofranil PM™
YES/$$$$
  • May take without regard to food
  • Tricyclic antidepressant
  • Inhibits norepinephrine and serotonin reuptake by neurons
Tofranil™
  • Depression
  • Childhood enuresis (bedwetting)

Tofranil PM™
  • Depression
NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more)
  • Dry mouth - > 50% of patients in some trials
  • Drowsiness - common
  • Blurred vision
  • Constipation
  • Urinary retention
  • Postural hypotension
  • Seizure - may increase risk
  • Serotonin syndrome
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Urinary retention - may worsen
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abnormal bleeding - through platelet inhibition
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - use caution
  • Kidney disease - use caution
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Nortriptyline

(Pamelor™)
Nortriptyline capsule
  • 10 mg
  • 25 mg
  • 50 mg
  • 75 mg
Depression
  • Starting: 25 mg a day
  • Maintenance: 25 - 100 mg a day given in 1 - 4 divided doses
  • Max: 150 mg a day

Herpes zoster neuralgia (off-label)
  • Starting: 25 mg at bedtime
  • Max: 150 mg a day
  • Increase by 25 mg daily every 2–3 days as tolerated
  • Dosing recommendation from the Infectious Disease Society of America
Pamelor™
YES/$
  • May take without regard to food
  • When taking doses > 100 mg a day, plasma levels of nortriptyline should be monitored. Ideal plasma level is 50 - 150ng/ml.
  • Tricyclic antidepressant
  • Inhibits norepinephrine and serotonin reuptake by neurons
  • Depression
NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more)
  • Dry mouth - > 50% of patients in some trials
  • Drowsiness - common
  • Blurred vision
  • Constipation
  • Urinary retention
  • Postural hypotension
  • Seizure - may increase risk
  • Serotonin syndrome
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Urinary retention - may worsen
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abnormal bleeding - through platelet inhibition
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - use caution
  • Kidney disease - use caution
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Trazodone

(Desyrel®)
(Oleptro™)
Trazodone tablet
  • 50 mg
  • 100 mg
  • 150 mg
  • 300 mg

Oleptro®
extended-release tablet

  • 150 mg
  • 300 mg
Depression

    Trazodone
    • Starting: 150 mg a day given in divided doses
    • Maintenance: 150 - 400 mg a day given in divided doses
    • Max: 400 mg a day
    • Increase dose by 50 mg/day every 3 - 4 days
    Oleptro™
    • Starting: 150 mg once daily
    • Maintenance: 150 - 300 mg once daily
    • Max: 375 mg once daily
    • Increase dose by 75 mg/day every 3 days

Insomnia (off-label)

    Trazodone
    • Starting: 50 mg at bedtime
    • Maintenance: 50 - 150 mg at bedtime
Trazodone
YES/$
Oleptro™
NO/$$$
Trazodone
  • When taken after a meal or light snack, absorption is increased
  • Trazodone tablets are scored and can be broken in half

Oleptro™
  • Oleptro™ tablets are scored and can be broken in half. Tablets should not be crushed or chewed.
  • Oleptro™ should be taken on an empty stomach, preferably at bedtime
  • Serotonin modulator
  • Blocks postsynaptic serotonin receptors and inhibits postsynaptic serotonin reuptake
  • Depression
  • Sleep aid - not FDA-approved
NOTE: P = % of patients on placebo who reported side effect
  • Drowsiness - 41%, P - 20%
  • Dry mouth - 34%, P - 20%
  • Dizzy/Lightheaded - 28%, P - 15%
  • Headache - 20%, P - 16%
  • Blurred vision - 15%, P - 4%
  • Nausea - 13%, P - 10%
  • Decreased libido - 1.3%, P - < 1%
  • Orthostatic hypotension
  • Priapism (erection lasting > 6 hours)
  • Seizure - may increase risk
  • Serotonin syndrome
  • Prolonged QT syndrome - may worsen QT prolongation
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - use caution
  • Kidney disease - use caution
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Vilazodone

(Viibryd®)
Viibryd® tablet
  • 10 mg
  • 20 mg
  • 40 mg

Starter kit:
10 mg X 7
20 mg X 7
40 mg X 16
Depression
  • Starting: 10 mg once daily for 7 days, then 20 mg once daily for 7 days, then 40 mg once daily
  • Maintenance: 40 mg once daily
  • Max: 40 mg once daily

When taken with CYP3A4 strong inhibitors
  • Dose should not exceed 20 mg a day

When taken with CYP3A4 moderate inhibitors
  • Dose should not exceed 20 mg a day in patients with significant side effects

When taken with CYP3A4 strong inducers
  • Consider doubling the dose
  • Viibryd® dose should not exceed 80 mg/day
Viibryd®
NO/$$$$
  • Take with food. Food increases absorption.
  • Serotonin modulator
  • Blocks postsynaptic serotonin receptors and inhibits postsynaptic serotonin reuptake
  • Depression
NOTE: P = % of patients on placebo who reported side effect
  • Diarrhea - 28%, P - 9%
  • Nausea - 23%, P - 5%
  • Dizziness - 9%, P - 5%
  • Dry mouth - 8%, P - 5%
  • Insomnia - 6%, P - 2%
  • Decreased libido - 4%, P - < 1%
  • Delayed ejaculation - 2%, P - 0%
  • Seizure - may increase risk
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Low sodium (hyponatremia) - may cause SIADH
  • Serotonin syndrome
  • Abnormal bleeding - through platelet inhibition
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease
    • Mild-moderate (Child-Pugh A/B): no dose adjustment necessary
    • Severe (Child-Pugh C): has not been studied
  • Kidney disease - no dose adjustment necessary
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Mirtazapine

(Remeron®)
(Remeron Soltab®)
Remeron® tablet
  • 7.5 mg
  • 15 mg
  • 30 mg
  • 45 mg

Remeron Soltab®
orally disintegrating tablet

  • 15 mg
  • 30 mg
  • 45 mg
Depression
  • Starting: 15 mg once daily at bedtime
  • Maintenance: 15 - 45 mg once daily at bedtime
  • Max: 45 mg once daily
  • Increase dose at intervals of no less than 1 - 2 weeks
Remeron®
YES/$
  • May take without regard to food

  • Soltabs® are placed on tongue where they dissolve and are swallowed. Water is not necessary.

  • Do not break Soltabs®

  • Use Soltabs® immediately after removing from blister pack. They cannot be stored.
  • Blocks alpha-2 adrenergic receptors which increases norepinephrine and serotonin activity
  • Blocks serotonergic 5-HT2 and 5-HT3 receptors which increases serotonergic activity
  • Blocks histamine receptors which causes sedation
  • Blocks alpha-1 receptors which may cause orthostatic hypotension
  • Blocks muscarinic receptors (anticholinergic effects)
  • Depression
NOTE: P = % of patients on placebo who reported side effect
  • Somnolence - 54%, P - 18%
  • Dry mouth - 25%, P - 15%
  • Increased appetite - 17%, P - 2%
  • Elevated cholesterol/triglycerides - 15%, P - 7%
  • Constipation - 13%, P - 7%
  • Weight gain - 12%, P - 2%
  • Dizziness - 7%, P - 3%
  • Elevated liver enzymes - 2%, P - 0.3%
  • Sexual side effects are comparable to placebo in trials
  • Orthostatic hypotension - may occur
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Low white blood cells - agranulocytosis has occurred in rare cases in patients taking mirtazapine
  • Low sodium (hyponatremia) - may cause SIADH
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease - clearance is decreased. No specific recommendations given. Use caution.
  • Kidney disease
    • CrCl 11 - 39 ml/min: clearance is decreased 30%
    • CrCl < 10 ml/min: clearance is decreased 50%; use caution
Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects Drug Interactions Precautions/
Contraindications
Vortioxetine

(Trintellix®)
Trintellix® tablet
  • 5 mg
  • 10 mg
  • 15 mg
  • 20 mg
Depression
  • Starting: 10 mg once daily
  • Maintenance: 20 mg once daily
  • Max: 20 mg once daily

When taken with CYP2D6 strong inhibitors
  • Reduce dose by half

CYP2D6 poor metabolizers
  • Maximum dose is 10 mg once daily

When taken with CYP3A4 strong inducers
  • Consider increasing the dose
  • Dose should not exceed three times the original dose
Trintellix®
NO/$$$$
  • May take without regard to food

  • Brand name was changed from Brintellix to Trintellix in 2016 to avoid confusion with Brilinta
  • Serotonin Reuptake Inhibitor
  • 5-HT3 receptor antagonist
  • 5-HT1A receptor agonist
  • Depression
NOTE: P = % of patients on placebo who reported side effect
  • Nausea - 32%, P - 9%
  • Dizziness - 9%, P - 6%
  • Dry mouth -8%, P - 6%
  • Constipation - 8%, P - 3%
  • Sexual dysfunction - 5%, P - 2%
  • CYP2D6 poor metabolizers - maximum dose is 10 mg once daily
  • Serotonin syndrome
  • Seizure - possible increase risk
  • Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
  • Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
  • Bipolar - may precipitate mania in bipolar patients
  • Abnormal bleeding - through platelet inhibition
  • Low sodium (hyponatremia) - may cause SIADH
  • Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
  • Liver disease
    • Mild-moderate (Child-Pugh A/B): no dose adjustment necessary
    • Severe (Child-Pugh C): has not been studied
  • Kidney disease - no dose adjustment necessary