VA / DOD DEPRESSION PRACTICE GUIDELINE PROVIDER CARE CARD ANTIDEPRESSANT MEDICATION TABLE CARD 7 Refer to pharmaceutical manufacturer’s literature for full prescribing information

SEROTONIN SELECTIVE REUPTAKE INHIBITORS (SSRIs) GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY

Citalopram Celexa 20 mg 60 mg Reduce dose Nausea, insomnia, Fluoxetine Prozac 20 mg 80 mg for the elderly & No serious systemic sedation, those with renal toxicity even after headache, fatigue Paroxetine Paxil 20 mg 50 mg or hepatic substantial overdose. dizziness, sexual AM daily dosing. failure Drug interactions may dysfunction Response rate = Can be started at Sertraline Zoloft 50 mg 200 mg include tricyclic anorexia, weight 2 - 4 wks an effective dose First Line Antidepressant Medication antidepressants, loss, sweating, GI immediately. Drugs of this class differ substantially in safety, tolerability and simplicity when used in patients carbamazepine & distress, tremor, warfarin. restlessness, on other medications. Can work in TCA (tricyclic antidepressant) nonresponders. Useful in agitation, anxiety. several anxiety disorders. Taper gradually when discontinuing these medications.

SEROTONIN and NOREPHINEPHRINE REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Reduce dose Take with food. Venlafaxine IR Effexor IR 75 mg 375 mg Comparable to BID or TID for the elderly & No serious systemic SSRIs at low dose. dosing with IR. those with renal toxicity. Nausea, dry mouth, Response rate = Daily dosing or hepatic Downtaper slowly to Venlafaxine XR Effexor XR 75 mg 375 mg insomnia, anxiety, 2 - 4 wks with XR. failure prevent clinically somnolence, head- (4 - 7 days at Can be started at significant withdrawal ache, dizziness, ~300 mg/day) an effective dose Dual action drug that predominantly acts like a Serotonin Selective Reuptake inhibitor at low syndrome. asthenia, abnormal (75 mg) doses and adds the effect of an Norepinephrine Selective Reuptake Inhibitor at high doses. Few drug interactions. ejaculation, immediately. Possible efficacy in cases not responsive to TCAs or SSRIs. Taper dose prior to discontinuation. sweating.

DOPAMINE and NOREPINEPHRINE REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Reduce dose BID or TID Bupropion - IR Wellbutrin - IR 200 mg 450 mg for the elderly & Seizure risk at doses dosing. those with renal higher than max or with Increase dose Bupropion - SR Wellbutrin - SR 150 mg 400 mg or hepatic other drugs that Rarely causes Response rate gradually to failure increase seizure risk. sexual dysfunction. = 2 - 4 wks decrease risk of Drug/drug interactions seizures. Least likely antidepressant to result in a patient becoming manic. Do not use if there is a history uncommon. Requires dose of seizure disorder, head trauma, bulimia or anorexia. Can work in TCA non-responders. titration.

NOREPINEPHRINE SELECTIVE REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY 75 - 200 mg 300 mg Reduce dose Response rate Can be given Desipramine * Norpramin * Serious toxicity can for the elderly & = 2 - 4 wks QD. Can start result from OD. 50 mg 150 mg those with renal effective dose Nortriptyline * Aventyl/Pamelor * Reserve Maprotiline as Therapeutic or hepatic immediately. a second-line agent Generally Good. levels: failure Monitor serum Maprotiline * * Ludiomil * * 75 mg 225 mg due to risk of seizures Desipramine level after one at therapeutic & 125-300 ng/mL Consider Desipramine or Nortriptyline first in the elderly if TCAs are necessary. week of nontherapeutic doses. Nortriptyline treatment. * Secondary Amine Tricyclic Antidepressants (SATCAs) * * Tetracyclic Antidepressant 50-150 ng/mL

VA/DoD Depression Clinical Practice Guideline April 2002

VA / DOD DEPRESSION PRACTICE GUIDELINE PROVIDER CARE CARD ANTIDEPRESSANT MEDICATION TABLE CARD 8

Refer to pharmaceutical manufacturer’s literature for full prescribing information SEROTONIN (5-H2A) RECEPTOR ANTAGONIST and WEAK SEROTONIN REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY

Nefazodone * Serzone * 200 mg 600 mg Reduce dose for the elderly & No serious systemic Somnolence, those with renal toxicity from OD. Can dizziness, fatigue, or hepatic interact with agents dry mouth, nausea, Trazodone Desyrel 150 mg 600 mg failure that decrease arousal, BID dosing. headache, Response rate = impair cognitive Requires dose constipation, 2 - 4 wks performance and titration. impaired vision. Corrects sleep disturbance and reduces anxiety in about one week. interact with adrenergic Unlikely to cause agents that regulate * Caution - Nefazodone Specific- Monitor for signs & symptoms of liver dysfunction; consider sexual dysfunction. LFT monitoring. Do not take with triazolam, alprazolam, pimozide, astemizole, cisapride & blood pressure. terfenadine due to increased plasma levels. If on Digoxin, monitor levels.

MIXED REUPTAKE and NEURORECEPTOR ANTAGONISTS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY

Amitriptyline * Elavil, Endep * 50 - 100 mg 300 mg Reduce dose Sedation, increased anticholinergic for those with Serious toxicity can Response rate Imipramine Tofranil 75 mg 300 mg effects, orthostatic Can be given * * renal or hepatic result from OD. = 2 - 4 wks hypotension, cardiac QD. Monitor failure Slow system Doxepin * Sinequan * 75 mg 300 mg conduction Therapeutic serum level after clearance. Can cause disturbances, Levels: one week of multiple drug/drug These antidepressants are not recommended for use in the elderly. arrhythmia & wt Imipramine treatment. interactions. Highest response rates. TATCAs useful in chronic pain, migraine headaches & insomnia. gain, dizziness, 200-350 ng/mL * Tertiary Amine Tricyclic Antidepressants (TATCAs). sexual dysfunction.

CAUTION: In rare cases initiating or titrating routine antidepressant medication can precipitate a manic episode in some individuals.

CAUTION: if patient is currently receiving an MAOI consult/refer to a behavioral health physician for medication prescribing.

NOTE: Antidepressant Medication Information current as of February 2002. May become outdated.

MEDICATIONS THAT CAN CAUSE DEPRESSION

QUALITY of STRENGTH of DRUG / DRUG CLASS EVIDENCE RECOMMENDATION I B Amphetamine withdrawal, Anabolic Steroids, Digitalis, Glucocorticoids I C Cocaine withdrawal II-1 C Reserpine II-2 A Gonadotropin-releasing agonists, Pimozide II-2 B Propanolol (Beta Blockers) ACE Inhibitors, Antihyperlipidemics, Benzodiazepines, Cimetidine, Ranitidine, Clonidine, Cycloserine, Interferons, II-2 C Levodopa, Methyldopa, Metoclopramide, Oral Contraceptives, Topiramate, Verapamil, (Calcium Channel Blockers) Although there is little published information on alternative medicines causing depression, consideration should also be given to herbal, nutritional, vitamins and body building supplements, particularly when consumed in large doses.