THE SECTION Psychiatric Disorders

MERCK MANUALS FOR HEALTHCARE

SUBJECT
TOPIC
Mood Disorders
Depressive Disorders
ONLINE MEDICAL LIBRARY PROFESSIONALS

ANTIDEPRESSANTS
Therapeutic
Drug Starting Dose* Dosage Range Precautions

Heterocyclics Contraindicated in patients

with coronary artery disease,
certain arrhythmias, angle-
closure glaucoma, benign
prostatic hypertrophy, or
esophageal hiatus hernia
Can cause orthostatic hypoten-
sion leading to falls and frac-
tures, potentiate the effect of
alcohol, and raise the blood
level of antipsychotics
With significant overdose,
potentially lethal
Amitriptyline 50 mg once/day 150–300 mg Causes weight gain
Amoxapine 50 mg bid 150–400 mg Can have extrapyramidal
adverse effects
Clomipramine 25 mg once/day 100–250 mg Lowers seizure threshold at
doses of > 250 mg/day
Desipramine 25 mg once/day 150–300 mg —
Doxepin 25 mg once/day 150–300 mg Causes weight gain
Imipramine 25 mg once/day 150–300 mg May cause excessive sweating
and nightmares
Maprotiline 75 mg once/day 150–225 mg Increased risk of seizures with
rapid dose escalation at high
doses
Nortriptyline 25 mg once/day 50–150 mg Effective within the therapeutic
window
Protriptyline 5 mg tid 15–60 mg Has long half-life (74 h)
Trimipramine 50 mg once/day 150–300 mg Causes weight gain
MAOIs Serotonergic syndrome possi-
ble when taken with an SSRI
or nefazodone
Hypertensive crisis possible
when taken with other antide-
pressants, sympathomimetic
or other selective drugs, or
certain foods and beverages
With significant overdose,
potentially lethal
Isocarboxazid 10 mg bid 30–60 mg Causes orthostatic hypotension
Phenelzine 15 mg tid 45–90 mg Causes orthostatic hypotension
Selegiline, 6 mg once/day 12 mg Can cause application site reac-
transdermal tions and insomnia
Tranylcypromine 10 mg bid 30–60 mg Causes orthostatic hypotension
Has amphetamine-type stimu-
lant effects and modest abuse
potential
 THE SECTION Psychiatric Disorders

MERCK MANUALS FOR HEALTHCARE

SUBJECT
TOPIC
Mood Disorders
Depressive Disorders
ONLINE MEDICAL LIBRARY PROFESSIONALS

ANTIDEPRESSANTS—Continued
Therapeutic
Drug Starting Dose* Dosage Range Precautions

SSRIs . Causes discontinuation symp-

toms if stopped abruptly (less
likely with fluoxetine)
Citalopram 20 mg once/day 20–40 mg Lower potential for drug
interactions because it has
less effect on CYP450
isoenzymes
Escitalopram 10 mg once/day 10–20 mg Same as for citalopram
Fluoxetine 10 mg once/day 20–60 mg Has very long half-life
Less likely to cause discontinu-
ation symptoms
The only antidepressant proven
effective in children
Fluvoxamine 50 mg once/day 100–200 mg Can cause clinically significant
elevation of theophylline,
warfarin, and clozapine blood
levels
Has potential for interactions
between its active metabo-
lites and HCAs, carba-
mazepine, antipsychotics, or
type IC antiarrhythmics; has
CYP450 profile similar to
fluoxetine
Paroxetine 20 mg once/day 20–50 mg Has potential for interactions
between its active metabo-
lites and HCAs, carba-
mazepine, antipsychotics, or
type IC antiarrhythmics; has
CYP450 profile similar to
fluoxetine
25 mg CR 25–62.5 mg CR May cause the most weight
once/day gain among SSRIs
Sertraline 50 mg once/day 50–200 mg Of SSRIs, has highest
incidence of loose stools
Serotonin-norepinephrine reuptake inhibitors Causes discontinuation symp-
toms if stopped abruptly
Duloxetine 20 mg bid 60–120 mg Modest dose-dependent
increase in systolic and dias-
tolic BP
May cause mild urinary hesi-
tancy in males
Less potential for drug-drug
interactions because it has
less effect on CYP450
 THE SECTION Psychiatric Disorders

MERCK MANUALS FOR HEALTHCARE

SUBJECT
TOPIC
Mood Disorders
Depressive Disorders
ONLINE MEDICAL LIBRARY PROFESSIONALS

ANTIDEPRESSANTS—Continued
Therapeutic
Drug Starting Dose* Dosage Range Precautions

Venlafaxine 25 mg tid 75–375 mg Modest dose-dependent

increase in diastolic BP
Dual norepinephrine and
5-HT reuptake effect at about
150 mg
37.5 mg XR 75–225 mg XR Rarely, increase in systolic BP
once/day (not dose-dependent)
If stopped, should be tapered
slowly
Less potential for drug-drug
interactions because it has
less effect on CYP450
Serotonin modulators (5-HT2 blockers)
Mirtazapine 15 mg once/day 15–45 mg Causes weight gain and
sedation
Has fewer sexual adverse
effects than SSRIs and
serotonin-norepinephrine
reuptake inhibitors
Nefazodone 100 mg once/day 300–500 mg May cause liver failure
Has fewer sexual adverse
effects than SSRIs and
serotonin-norepinephrine
reuptake inhibitors
Trazodone 50 mg tid 150–300 mg May cause priapism
May cause orthostatic
hypotension
Norepinephrine-dopamine-reuptake inhibitor
Bupropion 100 mg bid 200–450 mg Contraindicated in patients
150 mg SR who have bulimia or who are
once/day seizure-prone
150 mg XL May interact with HCAs,
once/day increasing the risk of seizures
May cause dose-dependent
recent memory loss

*All drugs are given orally except for transdermal selegiline.

CR = continuous release; CYP450 = cytochrome P450 system; HCAs = heterocyclic antidepres-
sants; 5-HT = 5-hydroxytryptamine (serotonin); MAOIs = monoamine oxidase inhibitors; SR =
sustained release; XL = extended release; XR = extended release.