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Commonly prescribed psychotropic medications

COMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS
po = by mouth; prn = as needed; qd = 1x day; bid = 2x/day; tid = 3x/day; qid = 4x/day; qod = every other day; qhs = at bedtime; qac = before meals; SSRI = Selective Serotonin Reuptake Inhibitor; SNRI = Serotonin Norepinephrine Reuptake Inhibitor;  on Wal-Mart’s $4 Rx plan, however not all dosages may be covered; ¢= generic available. $ = Not available as generic or expensive.
NAME Generic (Trade)
KEY CLINICAL INFORMATION
Antidepressant Medications
Contraindicated in seizure disorder because it decreases seizure threshold; stimulating; not good for treating anxiety disorders; second
Bupropion
(Wellbutrin) Start: IR-100 mg bid X 3d then ↑ to 100 mg tid; SR-150 mg qam X 3d then ↑ to 150
mg bid; XL-150 mg qam X 3d, then ↑ to 300 mg qam. Range: 300-450 mg/d.
line TX for ADHD; abuse potential. ¢ (IR/SR), $ (XL)
 Citalopram (Celexa)
Start: 10-20 mg qday. Range: 20–80 mg/d.
Best tolerated of SSRIs; very few and limited CYP 450 interactions; good choice for anxious pt. ¢
Duloxetine
(Cymbalta) Start: 20 mg bid up to 60 mg (qday or 30 mg bid). Range: 60-120 mg/d.
More GI side effects than SSRIs; tx neuropathic pain; need to monitor BP; 2nd line tx for ADHD. $
Escitalopram (Lexapro)
Start: 5-10 mg qday. Range: 10 – 30 mg/d (3X more potent than Celexa).
Best tolerated of SSRIs, very few and limited CYP 450 interactions. Good choice for anxious pt. $
 Fluoxetine (Prozac)
Start: 10 – 20 mg qam. Range: 20 – 60 mg/d.
More activating than other SSRIs; long half-life reduces withdrawal (t ½ = 4-6 d). ¢
Mirtazapine (Remeron)
Start: 15 mg qhs X 3d then ↑ to 30 mg qhs. Range: 30 – 60 mg/d.
Sedating and appetite promoting; Neutropenia risk (1 in 1000) so avoid in immunosupressed patients. ¢
 Paroxetine (Paxil)
Start: 10 – 20 mg qhs. Range: 20 – 60 mg/d.
Anticholinergic; sedating; very significant withdrawal syndrome. ¢
Sertraline (Zoloft)
Start: 25-50 qam. Range: 50-200 mg/d.
Few and limited CYP 450 interactions; mildly activating. ¢
More agitation & GI side effects than SSRIs; tx neuropathic pain above 150 mg qday; need to monitor BP; 2nd line tx for ADHD. Very significant
Venlafaxine
(Effexor) Start: IR-37.5 mg bid X 4d then ↑ to 75 mg bid; XR-75 mg qam X 4d then ↑ to 150
qAM. Range: 150-375 mg/d.
withdrawal syndrome. ¢ (IR), $ (XR)
*Antidepressant warnings/precautions: 1) Potential increased suicidality in first few months, 2) Long term weight gain likely (except Wellbutrin), 3) Sexual side effects common (except Wellbutrin), 4) Withdrawal syndrome frequently occurs with abrupt cessation (especially with SSRIs and SNRIs), Increased risk of bleeding with SSRIs and SNRIs (especially in combo with NSAIDs), 5) Increased risk for Serotonin Syndrome (except Wellbutrin), especially with combination of drugs effecting serotonin metabolism, 6) Hyponatremia sometimes seen with SSRIs and SNRIs. Antianxiety and Sleep (Hypnotic) Medications
Equiv. dose: 0.50 mg. Onset: intermediate (1-2 hrs). T½: 11 hrs. More addictive than other benzos and has uniquely problematic withdrawal
Alprazolam
Start: 0.25 mg – 0.5 mg tid. Usual MAX: 4 mg/d.
syndrome. Try to avoid as 1st line tx. ¢
Chlordiazepoxide
Equiv. dose: 25 mg. Onset: intermediate (0.5-2 hrs). T1/2: 10-48 hrs (parent compound), 14-95 hrs (metabolites). Useful for treating outpatient
(Librium)
Start: 10-20 mg 3-4X daily. Usual MAX: 200 mg/d
ETOH withdrawal because of long half-life. ¢
Clonazepam
(Klonopin) Start: 0.25 mg bid or tid. Usual MAX: 3 mg/d.
Equiv. dose: 0.25 mg. Onset: intermediate (1-4 hrs). T½: 40-50 hrs. Helpful in tx mania. ¢
Start: 2–10 mg bid to qid with doses depending on symptoms severity. Usual MAX:
Diazepam (Valium)
Equiv. dose: 5 mg. Onset: immediate (highly lipophilic). T½: 20-50 hrs. Note: the presence of liver disease will significantly lengthen half-life. ¢
Lorazepam (Ativan)
Start: 0.5-1 mg bid to tid. Usual MAX: 6 mg/d. Insomnia: 0.5-2 mg qhs.
Equiv. dose: 1 mg. Onset: intermediate. T½: 12 hrs. No active metabolites, so safer in liver dz. ¢
 Buspirone (Buspar)
Start: 7.5 mg bid. Range: 10-30 mg bid.
Non-benzo SSRI-like drug FDA approved for anxiety. May take 4-6 weeks to become fully effective. ¢
Hydroxazine (Vistaril)
Start: 25-100 mg 3-4 X per day. Usual MAX: 400 mg per day.
Antihistamine/antiemetic drug FDA approved for anxiety. Consider in pts w/ hx of substance abuse. ¢
Old antihypertensive used to tx nightmares and night sweats d/t PTSD. Need to warn about orthostasis particularly in AM after first dose and after Prazosin (Minipress)
Start: 1 mg qhs. Increase q 2-3 d until symptoms abate. Usual MAX: 10 mg qhs.
each new dosage change. ¢
 Trazodone (Desyrel)
Start: 25-50 mg qhs. Range: 50 – 150 mg/d.
Commonly used as sleep aid; must inform about priapism risk in men. ¢
Temazepam (Restoril)
Start: 15 mg at bedtime. MAX: 45 mg qhs.
T½: 8.8 hrs. Older benzo hypnotic. No P450 metabolism. More potential for physical dependence than Ambien/Sonata. ¢
Zolpidem (Ambien)
Start: 5-10 mg qhs. MAX: 20 mg qhs.
T½: 2.6 hrs. Potential for sleep-eating and sleep-driving. ¢ Available in longer acting form called Ambien CR $
Zaleplon (Sonata)
Start: 5-10 mg qhs. MAX: 20 mg qhs.
T½: 1 hr. Potential for sleep-eating and sleep-driving. $
Ramelteon (Rozerem)
Start: 8mg at bedtime.
Melatonin receptor agonist; Appears safe for long-term use. May take up to 1 wk to be effective. $
Mood Stabilizers
Start: 150-300 mg bid to tid with doses up to 1200 – 1500 mg daily and higher based
Black box warning for toxicity. Teratogenic (cardiac malform.) and will need to inform women of childbearing age of this risk. Check TSH
 Lithium
on renal function and drug levels (0.5 - 1.2 meq/L). Available in extended release
and BMP before starting and q 6-12 months thereafter. Advise pt about concurrent use of NSAIDS and HTN meds as can decrease renal clearance. Lithium strongly anti-suicidal. ¢ (lithium carbonate & citrate), $, (Lithobid, Eskalith)
Start: 750 mg daily in div. doses (bid or tid, DR; qday, ER); increase dose as quickly
Multiple black box warnings including for hepatotoxicity, pancreatitis, and teratogenicity (need to inform women of childbearing age of this
Divalproex (Depakote)
as tol. to clinical effect; usual trough plasma level: 50 to 125 mcg/mL.
risk). Need to monitor LFTs, platelet counts, and coags initially and q3-6 mo. Significant weight gain common. $
Start: 25 mg daily for 2 wks then 50 mg daily for 2 wks (may ↑ by 100 mg per wk
Black box warning for serious, life-threatening rashes requiring hospitalization and d/c of TX (Stevens Johnson syndrome @ approx. 1: 1-2000).
Lamotrigine
(Lamictal) thereafter) with a final dose of 200–300 mg (typically divided bid). Dosage will need to
No drug level monitoring typically required. Need to strictly follow published titration schedule. Fewer cognitive and appetite stimulating side be adjusted for patients taking enzyme-inducing drugs or Depakote. effects. $
Antipsychotic/ Mood Stabilizers**
EPS: moderate (especially akathisia); Metabolic side effects: low. Very long half-life: 75 hrs. Least amount of sexual side effects. Need to screen Aripiprazole
Start: 10-15 mg daily titrating (qweekly as needed) to 15–30 mg daily.
glucose and lipids regularly. $
Start: 0.5 – 1mg qhs or bid titrating to 4-6 mg daily or bid. Available as long-acting
EPS: highest; Metabolic side effects: moderate. Hyperprolactinemia and sexual side effects common. Need to screen glucose and lipids regularly. Risperidone (Risperdal)
injectable given q 2 weeks called Risperdal Consta. $
EPS: Low; Metabolic side effects: high. Weight gain and sedation common. Do not prescribe to diabetics. Need to screen glucose and lipids
Olanzapine (Zyprexa)
Start: 5 – 10mg daily titrating to 15 – 30 mg daily once or divided bid.
regularly. $
Start: 50 mg qhs titrating to 300 – 600 mg daily divided bid (max dose: 800mg). Newly
EPS: Lowest (except for Clozaril); Metabolic side effects: moderate. Highly sedating. Need to screen glucose and lipids regularly. Abuse
Quetiapine (Seroquel)
potential. FDA indication for bipolar depression. $
Start: 40 mg bid titrating quickly to 60–80 mg bid. Needs to be taken w/ food (doubles
EPS: moderately high (especially akathisia); Metabolic side effects: lowest. Need to screen glucose and lipids regularly. Lower dosage can be Ziprasidone
(Geodon) absorption).
more agitating than higher doses. $
 Haloperidol (Haldol)
Start: 0.5 to 5 mg daily or bid titrating to 5- 20 mg daily.
Classic typical, high potency neuroleptic. EPS common & ↑↑ risk of TD. Long acting injectable (Decanoate) available. ¢
Major Depressive Disorder: Limited or No Response to Treatment
Considerations
Is the patient taking the medication?
Poor adherence is common with all medications and antidepressants are no exception. Are there side effects that are limiting
compliance (e.g., sexual side effects)?

Is the dosage high enough?
One of the most frequent causes of lack of efficacy of antidepressants is under-dosing. If the patient has showed some response but has
not achieved remission to an adequate initial dosage (see guidelines in this document) after 4-6 weeks then increase the dosage. The
usual maximum dosages are listed below.

Is the diagnosis correct?
Other causes of depression requiring potentially different approaches include:
Bipolar depression. In bipolar depression antidepressants frequently do not work and can trigger a manic episode.
Depression secondary to a general medical condition. Causes include hypothyroidism, cerebrovascular accident, sleep apnea, and
Parkinson’s Disease.
Substance induced mood disorder.
• Is the patient taking medications that could be triggering depressive symptoms? Examples include steroids, interferon, and • Is the patient withdrawing from medications that could cause depression? Examples include withdrawal from cocaine, • Is the patient abusing alcohol or other CNS depressants?
Are there untreated co-morbid conditions that are exacerbating the symptoms?
Examples include anxiety disorders (PTSD, Panic D/O & OCD), personality disorders, and somatoform disorders.

Maximum Therapeutic Doses (mg/day) of Commonly Used Antidepressants

Bupropion (Wellbutrin)
Citalopram (Celexa)
Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Mirtazapine (Remeron)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafaxine (Effexor)

Good Reasons to Stop a Medication

• Dangerous interactions with other necessary medications • It was never “indicated” to begin with (wrong diagnosis or wrong medicine for correct diagnosis) • It has been at the maximum therapeutic dosage for 4-8 weeks with no response.
David A Harrison, MD, PhD. University of Washington 2008

Source: http://reachnola.org/pdfs/medicationcard.pdf

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