FDA-APPROVED USES OF PSYCHOTROPIC MEDICATIONS (adults) * Means “off-label use” (as listed in Epocrates) Note: Review detailed information in Epocrates before prescribing

AGORAPHOBIA • None

ALCOHOL USE DISORDER • acamprosate (Campral; CrCl 30-50: 333 mg tid; CrCl < 30 contraindicated) • disulfiram (Antabuse; pt must be abstinent from alcohol for > 12 h) • gabapentin* (review renal dosing) • naltrexone (50 mg; must be opioid free for 7-10 days) • topiramate* (CrCl 10-70: decr. dose 50%; CrCl <10: decr. dose 75%)

ALZHEIMER’S (and other) DEMENTIA-RELATED AGITATION (none are FDA-approved, but literature supported) • Citalopram: 20 mg = max dose in those > 60 yrs old; start at 5 mg in elderly pts • Nudexta: dextromethorphan/quinidine; FDA-approved for PBA; one (20mg/10mg) tab daily for one week, then one tab BID • Nuplazid: pimavanserin; FDA-approved for Parkinson’s disease psychosis; 34 mg daily • Antipsychotics: o Rexulti (brexpiprazole) 0.5 mg for 4-7 days, then 1 mg for 4-7 days, then 2 mg (target dose; may not show antipsychotic effect for 3-4 weeks) o Abilify (aripiprazole): start at 1-2 mg; better safety profile than risperidone o Risperdal (risperidone): start 0.125 mg in the very old; avoid in Parkinson’s pts due to higher EPS; higher side effect profile (dealths and CVAs) o Seroquel (quetiapine): often preferred by neurologists in Parkinson’s pts.

ALZHEIMER’S DEMENTIA (listed under “Neurology” in Epocrates) • donepezil (Aricept): mild to moderate dementia (10 mg); moderate to severe (10-23 mg) • galantamine (Razadyne): mild to moderate dementia • memantine (Namenda IR and XR): moderate to severe; CrCl 5-29: max 10 mg for IR or 14 mg for XR) • Namzaric (memantine/donepezil): moderate to severe; CrCl 5-29: max 10 mg for memantine IR or 14 mg for XR) • rivastigmine (Exelon…tabs: mild to moderate dementia; patch: mild to severe Alzheimer’s dementia)

ANOREXIA NERVOSA • cyproheptadine* (start 2 mg qid then increase to 8 mg qid)

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER • See Epocrates • Wellbutrin (IR, SR, ER)*

BINGE EATING DISORDER, MOD-SEVERE • Lisdexamfetamine (Vyvanse; eGFR 15-30: max 50 mg; eGFR <15: max 30 mg)

BIPOLAR DISORDER, ACUTE DEPRESSION • fluoxetine • lurasidone (Latuda; CrCl < 50: start 20 mg, max 60 mg) • quetiapine (IR max = 600 mg; ER max = 300 mg) • olanzapine

BIPOLAR DISORDER, ACUTE MANIC • Depakote • quetiapine IR: dose BID

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BIPOLAR I DISORDER, MAINTENANCE TREATMENT • asenapine (Saphris) • lamotrigine (CrCl 10-60: decr. dose 25%; CrCl < 10: 100 mg qod) • lithium (CrCl < 30: avoid use; CrCl 30-89: decr. starting dose, amt. not defined) • Tegretol* (carbamazepine; “Bipolar Disorder;” CrCl < 10: decr. dose 25%) • Trileptal* (oxcarbazepine; “Bipolar Disorder;” CrCl 10-50: decr. dose 25%; <10: decr 50%)

BIPOLAR I DISORDER, MANIC/MIXED • aripiprazole • asenapine (Saphris) • cariprazine (Vraylar; max = 6 mg) • lithium (CrCl < 30: avoid use; CrCl 30-89: decr. starting dose, amt. not defined) • olanzapine • quetiapine (IR and ER; dose IR at least BID) • risperidone (max = 6 mg) • ziprasidone

BIPOLAR ONE DISORDER, ACUTE DEPRESSION • cariprazine (Vraylar, max = 3 mg) • fluoxetine (max = 50 mg) • lurasidone (Latuda; CrCl < 50: start 20 mg, max 60 mg) • olanzapine • quetiapine (dose at HS; start 50 mg; doses >300 mg rarely effective)

BULIMIA NERVOSA • fluoxetine (max = 60 mg)

GENERALIZED ANXIETY DISORDER • alprazplam (max = 4mg; ER form not approved for this indication) • buspirone (start 7.5 mg bid) • clonazepam* (max = 4 mg) • escitalopram (Lexapro; max 10 mg in pts >60) • duloxetine (Cymbalta; start 30 mg) • hydroxyzine (CrCl < 50: decr. dose by 50%); NOTE: according to CMS: not appropriate for treatment of anxiety • lorazepam (max = 10 mg) • paroxetine (try to avoid) • quetiapine* (treatment-resistant; IR and ER, max = 300 mg q day) • venlafaxine (start 37.5-75 mg; max = 225 mg; CrCl 10-70: decr. dose 25-50%; CrCl < 10: decr. dose 50%)

INSOMNIA • diphenhydramine (Benadryl; try to avoid; anticholinergic = associated with increased risk of dementia) • doxepine (start at 3 mg; max = 6 mg) • eszopiclone (Lunesta; max = 3 mg; in elderly, debilitated pts, or sever liver impairment, max = 2 mg) • hydrozyzine* (CrCl < 50: decr. dose by 50%) • lorazepam (max = 4 mg) • melatonin (not FDA-approved; secreted by pineal gland; 1-10 mg at HS) • ramelteon (Rozerem; 8 mg; MT1 and MT2 receptor agonist, like melatonin, but not structurally related) • suvorexant (Belsomra) • trazodone* (max = 200 mg) • zoleplon (Sonata; max 10 mg in elderly; severe liver impairment, avoid use) • zolpidem (Ambien; max recommended dose in females = 5 mg; in pts > 60: max = 5 mg or 6.25 CR; avoid use in severe hepatic impairment)

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MAJOR DEPRESSIVE DISORDER • bupropion (IR, SR, XR) • citalopram (max = 20 mg in pts > 60) • desvenlafaxine (Pristiq; 50 mg; CrCl 30-50: max 50 mg; CrCl < 30: max 25 mg daily) • duloxetine (Cymbalta; start 30 mg; max = 120 mg) • escitalopram (Lexapro; max = 10 mg in pts > 60) • fluoxetine (max = 80 mg) • levomilnacipran (Fetzima; see renal dosing) • mirtazapine • paroxetine (try to avoid due to many side effects; highly anticholinergic; birth defects; elevated risk of breast CA and higher death rate for those with breast CA) • sertraline • trazodone (400-600 mg at HS) • venlafaxine (max IR = 375 mg, ER = 225 mg; CrCl 10-70: decr. dose 25-50%; CrCl < 10: decr. dose 50%) • vilazodone (Viibryd; start 10 mg; max = 40 mg) • vortioxetine (Trintellix; start 10 mg; max = 20 mg)

MAJOR DEPRESSIVE DISORDER, ADJUNCTIVE TREATMENT • aripiprazole (max = 15 mg) • brexpiprazole (Rexulti; CrCl < 60: max 2 mg) • olanzapine • quetiapine ER (max = 300 mg)

MAJOR DEPRESSIVE DISORDER, TREATMENT RESISTANT • fluoxetine (max = 50 mg)

NICOTINE DEPENDENCE • Chantix (varenicline) • Nicotine replacement meds • Wellbutrin SR (start 150 mg; max 300 mg)

OBSESSIVE-COMPULSIVE DISORDER (do not combine clomipramine and fluvoxamine) • Clomipramine (Anafranil; second line agent) • fluoxetine (max = 80 mg) • fluvoxamine (IR form: start 50 mg HS; max = 300 mg; ER form: start 100 mg HS; max = 300 mg; first line agent) • paroxetine (try to avoid) • sertraline

PANIC DISORDER • alprazolam (IR max dose = 4 mg; ER max dose = 6 mg) • clonazepam (max = 4 mg) • fluoxetine (max = 60 mg) • paroxetine (try to avoid) • propranolol (not FDA-approved; alternative to benzodiazepines; 10-20 mg bid to tid PRN) • sertraline (start with 25 mg) • venlafaxine ER (start 37.5 mg; max = 225 mg; CrCl 10-70: decr. dose 25-50%; CrCl < 10: decr. dose 50%)

PARKINSON’S DEMENTIA (listed under “Neurology” in Epocrates) • rivastigmine (Exelon…tabs and patch: mild to moderate Parkinson’s dementia)

PARKINSON’S PSYCHOSIS • pimavanserin (Nuplazid; can be tried “off-label” for other types of dementia-related psychosis)

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POSTTRAUMATIC STRESS DISORDER • paroxetine (try to avoid) • prazosin* (nightmares; start with 1 mg; 3-15 mg; note: ave. dose used in San Diego VA PTSD pts was apx. 7.5 mg) • sertraline (start with 25 mg) • topiramate* (nightmares; CrCl 10-70: decr. dose 50%; CrCl <10: decr. dose 75%) • venlafaxine ER* (start 37.5 mg; IR max = 300 mg; ER max = 375 mg; CrCl 10-70: decr. dose 25-50%; CrCl < 10: decr. dose 50%)

PREMENSTRUAL DYSPHORIC DISORDER • fluoxetine (max = 80 mg) • paroxetine (try to avoid) • sertraline (max = 150 mg)

PSEUDOBULBAR AFFECT • Nuedexta (dextromethorphan/quinidine)

SCHIZOAFFECTIVE DISORDER • buproprion XR • lithium* (CrCl < 30 avoid use; CrCl 30-89: decr. starting dose, amt. not defined) • paliperidone (CrCl 50-79: max 6 mg; CrCl 10-49: max 3 mg)

SCHIZOPHRENIA • asenapine (Saphris) • aripiprazole • brexpiprazole (Rexulti; CrCl < 60: max 3 mg) • cariprazine (Vraylar) • clozapine (treatment-resistant; suicide prevention, schizophrenia-associated) • lumateperone (Caplyta 42 mg (one CME said this has fewest side effects of all antipsychotic medications) • lurasidone (Latuda; CrCl < 50: start 20 mg, max 60 mg) • olanzapine • paliperidone (CrCl 50-79: max 6 mg; CrCl 10-49: max 3 mg) • quetiapine • risperidone (max = 16 mg…but generally stay < 8 mg; highest risk of EPS; avoid in Parkinson’s pts.) • ziprasidone (Geodon; can increase QTc interval)

SEASONAL AFFECTIVE DISORDER • bupropion ER

SOCIAL ANXIETY DISORDER • fluvoxamine* (Luvox ER: start 100 mg HS; max = 300 mg) • paroxetine (try to avoid) • sertraline (start with 25 mg) • venlafaxine ER (max = 75 mg; CrCl 10-70: decr. dose 25-50%; CrCl < 10: decr. dose 50%)

TARDIVE DYSKINESIA (VMAT2 inhibitors; listed under “Neurology” in Epocrates) • Austedo (deutetrabenzine) • Ingrezza (valbenazine)

TOURETTE SYNDROME • clonazepam* (max = 6 mg) • risperidone* (max = 6 mg)

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