Drugs Used for Mood Disorders
Objectives
2 Discuss the mood swings that are associated with bipolar disorder.
7 Compare the mechanism of action of SSRIs with that of other antidepressant agents.
8 Cite the advantages of SSRIs as compared with other antidepressant agents.
9 Examine the drug monograph for SSRIs to identify significant drug interactions.
Key Terms
mood (
) (p. 251)
mood disorder (
) (p. 251)
neurotransmitters (
) (p. 251)
dysthymia (
) (p. 252)
depression (
) (p. 252)
cognitive symptoms (
) (p. 252)
psychomotor symptoms (
) (p. 252)
bipolar disorder (
) (p. 252)
mania (
) (p. 252)
euphoria (
) (p. 252)
labile mood (
) (p. 253)
grandiose delusions (
) (p. 253)
cyclothymia (
) (p. 253)
suicide (
) (p. 253)
antidepressants (
) (p. 254)
Mood Disorders
Mood is a sustained emotional feeling perceived along a normal continuum of sad to happy, and it affects our perception of our surroundings. A mood disorder (affective disorder) is present when certain symptoms impair a person’s ability to function for a time. Mood disorders are characterized by abnormal feelings of depression or euphoria. They involve the prolonged and inappropriate expression of emotion that goes beyond brief emotional upset from negative life experiences. In severe cases, other psychotic features may also be present. About 15% to 20% of the U.S. population will have a diagnosable mood disorder during their lifetime.
http://evolve.elsevier.com/Clayton
The first Surgeon General’s Report on Mental Health (1999) recognized that the effect of mental illness on health and productivity has been profoundly underestimated. Major depression currently ranks as the second leading cause of disease burden (i.e., years lived with the disability) in the United States; the leading cause is ischemic heart disease. Unfortunately, the majority of people with depression receive no treatment. Undertreatment of mood disorders stems from many factors, including social stigma, financial barriers, underrecognition by health care providers, and underappreciation by the general public of the potential benefits to treatment. The symptoms of depression, such as feelings of worthlessness, excessive guilt, and lack of motivation, deter people from seeking treatment. Members of racial and ethnic minority groups often encounter additional barriers.
The underlying causes of mood disorders are still unknown. They are too complex to be completely explained by a single social, developmental, or biologic theory. A variety of factors appear to work together to cause depressive disorders. It is known that patients with depression have changes in the brain neurotransmitters norepinephrine, serotonin, dopamine, acetylcholine, and gamma-aminobutyric acid (GABA), but other unexpected negative life events (e.g., the sudden death of a loved one, unemployment, medical illness, other stressful events) also play a major role. Endocrine abnormalities such as excessive secretion of cortisol and abnormal thyroid-stimulating hormone (TSH), have been found in 45% to 60% of patients with depression. Genetic factors also predispose patients to developing depression. Depressive disorders and suicide tend to cluster in families, and relatives of patients with depression are two to three times more likely to develop depression. Medicines being taken for other diseases may also contribute to depression, including antihypertensives (e.g., reserpine, methyldopa, clonidine, beta-adrenergic blocking agents), anti-Parkinson medicines (e.g., levodopa), and hormones (e.g., estrogens, progestins, corticosteroids).
Mood disorders are divided into four primary types: (1) major depressive disorder (MDD); (2) dysthymia; (3) bipolar disorder; and (4) cyclothymia. Major depression and dysthymia are known as unipolar disorders, manifested by varying degrees of depression. Patients with MDD suffer from one or more specific episodes of depression, whereas patients with dysthymia suffer from more chronic, ongoing symptoms of depression that are not as severe as those of MDD. Bipolar disorder and cyclothymia are disorders characterized by episodes of depression that alternate with episodes of varying degrees of mania; these disorders are described in more detail later in this chapter.
The onset of a depressive disorder tends to occur during the late 20s, although it can occur at any age. The lifetime frequency of depressive symptoms appears to be as high as 26% for women and 12% for men. Risk factors for depression include a personal or family history of depression, prior suicide attempts, female gender, lack of social support, stressful life events, substance abuse, and medical illness. The American Psychiatric Association classifies episodes of depression as mild, moderate, and severe. Mild depression causes only minor functional impairment. Moderate depression involves an intermediate degree of impairment and affects both symptomatology and functionality. Patients with severe depression have several symptoms that exceed the minimum diagnostic criteria, and daily functioning is significantly impaired; hospitalization may be required.
It is beyond the scope of this text to discuss mood disorders in detail, but this discussion describes general types of symptoms associated with mood disorders. Patients experiencing depression display varying degrees of emotional, physical, cognitive, and psychomotor symptoms. Emotionally, the depression is characterized by a persistent, reduced ability to experience pleasure in life’s usual activities, such as hobbies, family, and work. Patients frequently appear sad, and a personality change is common. They may describe their mood as sad, hopeless, or blue. Patients often feel that they have let others down, although these feelings of guilt are unrealistic. Anxiety symptoms (see Chapter 16) are present in almost 90% of depressed patients. Physical symptoms often motivate the person to seek medical attention. Common physical symptoms seen in patients with depression include chronic fatigue, sleep disturbances such as frequent early morning awakening (terminal insomnia), appetite disturbances (weight loss or gain), and other symptoms such as stomach complaints or heart palpitations. Cognitive symptoms, such as the inability to concentrate, slowed thinking, confusion, and poor memory of recent events, are particularly common in older patients with depression. Psychomotor symptoms of depression include slowed or retarded movements, thought processes, and speech or, conversely, agitation manifesting as purposeless, restless motion (e.g., pacing, hand wringing, outbursts of shouting).
Life Span Considerations
Depression
The patient and caregivers must understand the importance of continuing to take the prescribed antidepressant medication despite a minimal initial response. The lag time of 1 to 4 weeks between the initiation of therapy and the therapeutic response must be emphasized. In most cases, the symptoms of depression may improve within a few days (e.g., improved appetite, sleep, psychomotor activity). However, the depression still exists, and monitoring should be continued for negative thoughts, feelings, and behaviors. Suicide precautions should be maintained until assessment indicates that suicidal ideation is no longer present.
Suicide statistics are varied and not well documented. Adolescents and older adults with depression are more likely to have suicidal ideation, and older adults commit suicide more frequently than depressed people of other age-groups. It appears that older adults are quite serious when attempting suicide because one in two attempts is successful.
Suicide is the third leading cause of death in adolescents; the incidence may be even higher because of underreporting. Suicide is a call for help; however, it is permanent when successfully completed. All comments about suicide or suicide gestures should be taken seriously.
Bipolar disorder (formerly known as manic depression), another disorder, is characterized by distinct episodes of mania (elation, euphoria) and depression separated by intervals without mood disturbances. The patient displays extreme changes in mood, cognition, behavior, perception, and sensory experiences. At any one time, a patient with bipolar disorder may be manic or depressed, exhibit symptoms of both mania and depression (mixed), or be between episodes.
The depressive state has been previously described. Symptoms of acute mania usually begin abruptly and escalate over several days. These symptoms include a heightened mood (euphoria), quicker thoughts (flight of ideas), more and faster speech (pressured speech), increased energy, increased physical and mental activities (psychomotor excitement), decreased need for sleep, irritability, heightened perceptual acuity, paranoia, increased sexual activity, and impulsivity. There is often a labile mood, with rapid shifts toward anger and irritability. The attention span is short, resulting in an inability to concentrate. Anything in the environment may change the topic of discussion, leading to flight of ideas. Social inhibitions are lost, and the patient may become disruptive and loud, departing suddenly from the social interaction and leaving everything in disarray. As the manic phase progresses, approximately two-thirds of patients with bipolar disorder develop psychotic symptoms (see Chapter 18), primarily paranoid or grandiose delusions, if treatment interventions have not been initiated. Unfortunately, most manic patients do not recognize the symptoms of illness in themselves and may resist treatment. Cyclothymia is a milder form of bipolar illness characterized by episodes of depression and hypomania that are not severe enough to meet the criteria for bipolar disorder.
Bipolar disorder occurs equally in men and women, with a prevalence rate of 0.4% to 1.6% in the adult population of the United States. The onset of bipolar disorder is usually during late adolescence or the early 20s. It is rare before adolescence, and it may occur as late as age 50. Approximately 60% to 80% of patients with bipolar disease will begin with a manic episode. Without treatment, episodes last from 6 months to a year for depression and for approximately 4 months for mania.
People with mood disorders have a high incidence of attempting suicide. The frequency of successful suicide is 15%, which is 30 times higher than that of the general population. All patients with depressive symptoms should be assessed for suicidal thoughts (suicidal ideation). Factors that increase the risk of suicide include increasing age, being widowed, being unmarried, unemployment, living alone, substance abuse, previous psychiatric admission, and feelings of hopelessness. The presence of a detailed plan with the intention and ability to carry it out indicate strong intent and a high risk for suicide. Other hints of potential suicidal intent include changes in personality, a sudden decision to make a will or give away possessions, and the recent purchase of a gun or hoarding a large supply of medications, including antidepressants, tranquilizers, or other toxic substances.
The prognosis for mood disorders is highly variable. Of patients with major depression, 20% to 30% recover fully and do not experience another bout of depression. Another 50% have recurring episodes, often with a year or more separating the events. The remaining 20% have a chronic course with persistent symptoms and social impairment. Most treated episodes of depression last approximately 3 months; untreated ones last 6 to 12 months. Patients with bipolar illness are more likely to have multiple subsequent episodes of symptoms.
Treatment of Mood Disorders
Mood disorders are treated with nonpharmacologic and pharmacologic therapy. Cognitive behavioral therapy, psychodynamic therapy, and interpersonal therapy with pharmacologic treatment have been more successful than any one treatment alone. Psychotherapy improves psychosocial function, interpersonal relationships, and day-to-day coping. Patients and family members should be taught to recognize the signs and symptoms of mania as well as those of depression, and the importance of treatment compliance to minimize the recurrence of the illness should be stressed. Patients should be encouraged to target symptoms that help them recognize mood changes and to seek treatment as soon as possible.
Most patients pass through three stages—acute, continuation, and maintenance—before full function is restored. The acute stage is the period from diagnosis to initial treatment response. The initial response occurs when the symptoms become so significantly reduced that the person no longer fits the criteria for the illness. The acute phase for medication response typically takes 10 to 12 weeks, during which time the patient is seen by the health care provider weekly or biweekly to monitor symptoms and adverse effects, to make dosage adjustments, and to provide support. Psychotherapies are initiated at the same time. Treatment of the acute phase is often prolonged because about half of patients become noncompliant with the medication and the psychotherapy or abandon the program. The goals of the continuation phase of therapy are to prevent relapse and to consolidate the initial response into a complete recovery (defined as being symptom-free for 6 months). The continuation phase involves 4 to 9 months of combined pharmacotherapy and psychotherapy for patients with a first episode of major depressive disorder. Maintenance phase therapy is recommended for individuals with a history of three or more depressive episodes, chronic depression, or bipolar disorder. The goal of maintenance phase therapy is to prevent recurrences of the mood disorder; patients may receive pharmacologic and nonpharmacologic therapy for this condition for a year or more.
Another form of nonpharmacologic treatment for depression and bipolar illness is electroconvulsive therapy (ECT). When performed under the guidelines provided by the American Psychiatric Association, ECT is safe and effective for all subtypes of major depression and bipolar disorders. It is more effective, more rapid in onset of effect, and safer for patients with cardiovascular disease than many drug therapies. A course of ECT usually consists of 6 to 12 treatments, but the number is individualized to the needs of the patient. Patients are now premedicated with anesthetics and neuromuscular blocking agents to prevent many of the adverse effects previously associated with ECT. Although it has been misused, ECT should be viewed as a treatment option that can be lifesaving for patients who otherwise would not recover from depressive illness. It is usually followed by drug therapy to minimize the rate of relapse.
Drug Therapy for Mood Disorders
Actions
Pharmacologic treatment of depression is recommended for patients with symptoms of moderate to severe depression, and it should be considered for patients who do not respond well to psychotherapy. Several classes of drugs, collectively known as antidepressants, are used for treatment. Antidepressants can be subdivided into three categories:
The second-generation antidepressants have similar efficacy and lower toxicity with overdose than the first-generation antidepressants, so they are recommended as first-line agents.
All antidepressants have varying degrees of effects on norepinephrine, dopamine, and serotonin by blocking reuptake and reducing destruction of these neurotransmitters, thereby prolonging their action. The development of a clinical antidepressant response requires at least 2 to 4 weeks of therapy at adequate dosages. In general, the antidepressant used for therapy should be changed if there is no clear effect within 4 to 6 weeks. Although much is known about the pharmacologic actions of antidepressants, the exact mechanism of action of these agents for treating depression is still unknown. However, it is now understood that depression is not simply a deficiency of neurotransmitters.
Uses
Two factors are important when selecting an antidepressant drug: the patient’s history of response to previously prescribed antidepressants and the potential for adverse effects associated with different classes of antidepressants. Contrary to marketing claims, there are no differences among antidepressant drugs (with the exception of the MAOIs) in relative overall therapeutic efficacy and onset caused by full therapeutic dosages. However, there are substantial differences in the adverse effects caused by different agents. It is not possible to predict which drug will be the most effective for an individual patient, but patients do show a better response to a specific drug, even within the same class of drugs. About 30% of patients do not show appreciable therapeutic benefit with the first agent used, but they may have a high degree of success with a change in medication. The history of previous treatment is helpful during the selection of new treatment if illness returns. Approximately 65% to 70% of patients respond to antidepressant therapy, and 30% to 40% achieve remission. Therapy is based on a patient’s history of previous response or the successful response of a first-degree relative who responded to antidepressant therapy. Concurrent medical conditions such as obesity, seizure history, potential for dysrhythmias, presence of anxiety, and potential for drug interactions must also be considered in therapy selection. Certain types of mood disorders respond to medication more readily than others. Therapeutic success with TCAs can be improved by monitoring and maintaining therapeutic serum levels and adjusting dosages as needed. Serum levels of other classes of antidepressants generally do not correlate well with success in therapy, but they may be helpful to determine whether the patient is adhering to the dosage regimen or suffering from toxicities associated with higher serum levels. Recent changes in practice guidelines emphasize the need for continuing drug therapy for all patients; lifelong maintenance therapy will be required for some patients. The dosages of continuance and maintenance therapy must also be the same as the acute dose effective for eliminating depressive symptoms. When patients are given lower maintenance dosages, the risk of relapse is significantly greater than when doses are maintained at acute dose levels.
Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in short-term studies of children and adolescents with MDD and other psychiatric disorders. Anyone considering the use of an antidepressant for a child or an adolescent must balance the risk with the clinical need. When therapy is started, patients must be closely observed for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers need to be advised about the need for close observation and communication with the prescriber. Pooled analyses of short-term (4 to 16 weeks) placebo-controlled trials of nine antidepressant drugs (SSRIs and others) in children and adolescents with MDD, obsessive–compulsive disorder, or other psychiatric disorders—a total of 24 trials involving more than 4400 patients—have revealed a greater risk for adverse reactions representing suicidal thinking or behavior during the first few months of treatment in those receiving antidepressants. The average risk of such reactions in patients receiving antidepressants was 4%, which was twice the placebo risk of 2%. No suicides occurred during these trials.
Patients must be counseled about expected therapeutic benefits and adverse effects to be tolerated because of antidepressant therapy. The physiologic manifestations of depression (e.g., sleep disturbance, change in appetite, loss of energy, fatigue, palpitations) begin to be alleviated within the first week of therapy. The psychological symptoms (e.g., depressed mood, lack of interest, social withdrawal) will improve after 2 to 4 weeks of therapy at an effective dosage. Therefore, it may take 4 to 6 weeks to adjust the dosage to optimize therapy and to minimize adverse effects. Unfortunately, some adverse effects develop early in therapy, and patients who are already pessimistic because of their illness have a tendency to become noncompliant.
The pharmacologic treatment of bipolar disorder must be individualized because the clinical presentation, severity, and frequency of episodes vary widely among patients. Acute mania is initially treated with lithium, valproate, or an atypical antipsychotic agent (e.g., olanzapine, risperidone) as monotherapy. When stabilized, most patients are placed on long-term lithium therapy to minimize future episodes. Therapy with carbamazepine, oxcarbazepine, divalproex (valproic acid), lamotrigine, or gabapentin may be used for patients who do not adequately respond to lithium.
Nursing Implications for Mood Disorder Therapy
Assessment
History of Mood Disorder
Basic Mental Status
Interpersonal Relationships
Mood and Affect
Clarity of Thought.
Evaluate the coherency, relevancy, and organization of the patient’s thoughts; observe for flight of ideas, hallucinations, delusions, paranoia, or grandiose ideation. Ask specific questions about the individual’s ability to make judgments and decisions. Is there evidence of memory impairment? Identify areas in which the patient is capable of providing input to set goals and make decisions. (This will help the individual overcome a sense of powerlessness regarding life situations.) When the patient is unable to make decisions, plan to make them. Set goals to involve the patient because abilities change with treatment. Provide an opportunity to plan for self-care.
Thoughts of Death.
If the individual is suspected of being suicidal, ask the patient whether he or she has ever had thoughts about suicide. If the response is “yes,” get more details. Has a specific plan been formulated? How often do these thoughts occur? Does the patient make direct or indirect statements regarding death (e.g., “things would be better” if death occurred)?
Psychomotor Function.
Ask specific questions about the activity level the patient has maintained. Is the person able to work or go to school? Is the person able to fulfill responsibilities at work, socially, and within the family? How have the person’s normal responses to daily activities been altered? Is the individual withdrawn and isolated or still involved in social interactions? Check gestures, gait, pacing, presence or absence of tremors, and ability to perform gross or fine motor movements. Is the patient hyperactive or impulsive? Note the speech pattern. Are there prolonged pauses before answers are given or altered levels of volume and inflection?
Sleep Pattern.
What is the patient’s normal sleep pattern, and how does it vary with mood swings? Ask specifically whether insomnia is present and whether it is initial (falling asleep) or terminal (staying asleep) in nature. Ask the individual to describe the perception of the amount and quality of sleep nightly. Are naps taken regularly?
Dietary History.
Ask questions about the patient’s appetite, and note weight gains or losses not associated with intentional dieting. During the manic phase, the individual may become anorexic. Is the person able to sit down to eat a meal, or does he or she only eat small amounts while pacing?
Nonadherence.
Nonadherence is usually expressed by the denial of the severity of the disease. In addition, listen for excuses that the patient may make for not taking prescribed medicine (e.g., cannot afford it, asymptomatic, “I don’t like the way it changes me. I want to be myself!”).
Therapeutic Outcome
Plan through the acute, continuation, and maintenance phases of care delivery to help the patient achieve the highest level of independent functioning.
Implementation
Patient Education and Health Promotion
• Explain the unit rules and the therapeutic rules.
• Explain the activity groups available and how and when the individual will participate in them.
Fostering Health Maintenance
Written Record.
Enlist the patient’s help with developing and maintaining a written record of monitoring parameters. See the Patient Self-Assessment Form for Antidepressants on the Evolve Web site
, and complete the Premedication Data column for use as a baseline to track the patient’s response to drug therapy. Ensure that the patient understands how to use the form, and instruct the patient to bring the completed form to follow-up visits. During follow-up visits, focus on issues that will foster adherence with the therapeutic interventions prescribed.
Clinical Pitfall
Antidepressants may increase the risk of suicidal thinking and behavior (suicidality) in patients of all ages who are experiencing major depressive disorder. Patients who are started on antidepressants should be monitored daily by family members and caregivers for the emergence of agitation, irritability, unusual changes in behavior, and suicidality. Such symptoms should be immediately reported to health care providers.
Drug Therapy for Depression
Drug Class: Monoamine Oxidase Inhibitors
During the early 1950s, isoniazid and iproniazid were developed to treat tuberculosis. It was soon reported that patients treated with iproniazid exhibited mood elevation. After further investigation, it was discovered that iproniazid—in addition to having antitubercular properties, inhibited monoamine oxidase—whereas isoniazid did not. Other monoamine oxidase inhibitors (MAOIs) were synthesized and used extensively to treat depression until the 1960s, when the tricyclic antidepressants (TCAs) became available.
Actions
Monoamine oxidase inhibitors block the metabolic destruction of epinephrine, norepinephrine, dopamine, and serotonin neurotransmitters by the enzyme monoamine oxidase in the presynaptic neurons of the brain. As a result, the concentration of these central nervous system (CNS) neurotransmitters becomes increased. Although MAO inhibition starts within a few days after initiating therapy, the antidepressant effects require 2 to 4 weeks to become evident. Approximately 60% of the clinical improvement of symptoms of depression occurs after 2 weeks, and maximum improvement is usually attained within 4 weeks.
Uses
The MAOIs used today are phenelzine, tranylcypromine, isocarboxazid, and selegiline (Table 17-1). They are equally effective, and they have similar adverse effects. They are most effective for atypical depression, panic disorder, obsessive–compulsive disorder, and some phobic disorders. Selegiline is approved for treatment of major depressive disorder. They are also used when TCA therapy is unsatisfactory and when ECT is inappropriate or refused. Selegiline is available as a transdermal patch that should be changed once every 24 hours. Patients using the lowest strength available (6 mg) do not have dietary restrictions. However, dietary restrictions are required for those using the 9- and 12-mg patches.
Table 17-1
| GENERIC NAME | BRAND NAME | AVAILABILITY | INITIAL ORAL DOSAGE (UNLESS OTHERWISE NOTED) | DAILY MAINTENANCE DOSAGE (mg) | MAXIMUM DAILY DOSAGE (mg) |
| Monoamine Oxidase Inhibitors | |||||
| phenelzine | Nardil | Tablets: 15 mg | 15 mg three times daily | 15-60 | 90 |
| tranylcypromine | Parnate | Tablets: 10 mg | 10 mg twice daily | 30 | 60 |
| isocarboxazid | Marplan | Tablets: 10 mg | 10 mg twice daily | 40 | 60 |
selegiline Do not confuse selegiline with Serentil, sertraline, Serzone, or Salagen. | Emsam | Patch, transdermal: 6, 9, 12 mg | 6-mg patch daily | 6 | 12 |
| Tricyclic Antidepressants | |||||
amitriptyline Do not confuse amitriptyline with aminophylline. | — | Tablets: 10, 25, 50, 75, 100, 150 mg | 25 mg three times daily | 150-250 | 150 (outpatients) 300 (inpatients) |
| amoxapine | — | Tablets: 25, 50, 100, 150 mg | 50 mg three times daily | 200-300 | 400 (outpatients) 600 (inpatients) |
| clomipramine | Anafranil, Apo-Clomipramine  | Capsules: 25, 50, 75 mg | 25 mg three times daily | 100-150 | 250 |
| desipramine | Norpramin | Tablets: 10, 25, 50, 75, 100, 150 mg | 25 mg three times daily | 75-200 | 300 |
doxepin Do not confuse doxepin with digoxin. | Sinequan Apo-Doxepin  Do not confuse Sinequan with Serentil, Serzone, Seroquel, or Singulair. | Capsules: 10, 25, 50, 75, 100, 150 mg Oral concentrate: 10 mg/mL | 25 mg three times daily | At least 150 | 300 |
| imipramine hydrochloride | Tofranil, Apo-Imipramine  | Tablets: 10, 25, 50 mg | 30-75 mg daily at bedtime | 50-150 | 200 (outpatients) 300 (inpatients) |
| imipramine pamoate | Tofranil PM | Capsule: 75, 100, 125, 150 mg | 75-150 mg daily at bedtime | 75-150 mg | |
| nortriptyline | Pamelor, Nu-Nortriptyline  | Capsules: 10, 25, 50, 75 mg Solution: 10 mg/5 mL | 25 mg three or four times daily | 50-75 | 100 |
| protriptyline | Vivactil | Tablets: 5, 10 mg | 5-10 mg three or four times daily | 20-40 | 60 |
| trimipramine | Surmontil | Capsules: 25, 50, 100 mg | 25 mg three times daily | 50-150 | 200 (outpatients) 300 (inpatients) |
| Selective Serotonin Reuptake Inhibitors | |||||
| citalopram | Celexa Do not confuse Celexa with Zyprexa or Celebrex. | Tablets: 10, 20, 40 mg Liquid: 10 mg/5 mL | 20 mg daily | 20-40 | 60 |
| escitalopram | Lexapro Do not confuse Lexapro with loxapine. | Tablets: 5, 10, 20 mg Liquid: 1 mg/mL | 10 mg daily | 10-20 | 20 |
fluoxetine  Do not confuse fluoxetine with fluphenazine, fluvoxamine, famotidine, fluvastatin, or paroxetine. | Prozac Nu-Fluoxetine   Do not confuse Prozac with Prilosec, Proscar, or ProSom. | Capsules: 10, 20, 40 mg Tablets: 10, 20, 40, 60 mg Solution: 20 mg/5 mL Capsule, weekly: 90 mg | 20 mg in the morning | 20-60 | 80 |
fluvoxamine Do not confuse fluvoxamine with fluoxetine. | Luvox Do not confuse Luvox with Lasix, Levoxyl, or Lovenox. | Tablets: 25, 50, 100 mg Capsules, sustained release: 100, 150 mg | 50 mg at bedtime | 100-300 | 300 |
paroxetine Do not confuse paroxetine with fluoxetine, paclitaxel, or pyridoxine. | Paxil Do not confuse Paxil with paclitaxel, Plavix, or Taxol. | Tablets: 10, 20, 30, 40 mg Suspension: 10 mg/5 mL | 20 mg daily | 20-50 | 50 |
| Paxil CR | Tablets, sustained release: 12.5, 25, 37.5 mg | ||||
sertraline Do not confuse sertraline with selegiline, Serentil, Serzone, Seroquel, or Singulair. | Zoloft Apo-Sertraline   Do not confuse Zoloft with Zocor, or Zyloprim. | Tablets: 25, 50, 100 mg Oral concentrate: 20 mg/mL | 50 mg daily | 50-200 | 200 |
| Serotonin and Norepinephrine Reuptake Inhibitors | |||||
| desvenlafaxine | Pristiq | Tablets, sustained release: 50, 100 mg | 50 mg daily at the same time | 50-400 | 400 |
| duloxetine | Cymbalta Do not confuse Cymbalta with Zyprexa, Celebrex, or Cerebra. | Capsules, sustained release: 20, 30, 60 mg | 40 mg daily | 60 | 60 |
| venlafaxine | Effexor | Tablets: 25, 37.5, 50, 75, 100 mg Capsules, tablets, sustained release: 37.5, 75, 150, 225 mg | 75 mg in two or three doses daily, taken with food | 75-375 | 375 in three divided doses daily |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
