Essentials of Psychiatry in Primary Care: Behavioral Health in the Medical Setting >Major Depression and

Related Disorders
Robert C. Smith, Gerald G. Osborn, Francesca C. Dwamena, Dale D'Mello, Laura Freilich, Heather S. Laird-Fick+
Table 4-5.Use of Antidepressant Medications in Depressive Disorders

Antidepressant Medications Antidepressant Side Effects

Initial Dosea Therap. Dose

Class Half-Life Sedation Weight Gain Sexual Cardiac Anticholinergic Seizures Drug Interactionb
(mg/d) (mg/d)

SSRI

2D6 inhibitor
Sertraline
+/−
50 100-200 Medium +/− + ++ − + −
Zoloft
At high doses
only

2D6 inhibitor
Fluoxetine 4+
20 20-60 Long − +/− ++ − + −
Prozac Incr. flecainide
and β-blocker
level

Citalopram
Incr. flecainide
20 20-60 Short +/− + ++ QTc increased − −
level
Celexa

Escitalopram
Incr. flecainide
10 10-20 Short − + ++ QTc increased − −
level
Lexapro

2D6 inhibitor
Paroxetine 4+
20 20-40 Short + ++ +++ − + −
Paxil Incr. flecainide
and β-blocker
level

SNRI

Venlafaxine
Increased BP
XR Decr. Indinavir
37.5 75-225 Short − +/− +++ &heart − −
level
Effexor XR
rate

Duloxetine
2D6 inhibitor
30 30-60 Short − +/− +++ +/− − −
1+
Cymbalta

OTHER
 Mirtazapine
15 15-45 ++ +++ + − − −
Remeron

+ Increased 2D6 inhibitor

Bupropion 75-150 300-450 − − − +++ +++
1+
BP

Bupropion SR
100 300-400
− − − + Increased BP +++ +++
Wellbutrin SR
(50 bid) (used bid)

Bupropion XL
150 300-450 − − − + Increased BP +++ +++
Wellbutrin XL

2D6 = P450 2D6 pathway23-25; BP = blood pressure; QTc = corrected QT interval on an electrocardiogram where abnormal with increased risk for arrhythmias is >470 in women and >450 in men—especially
risky when >500, at which point medication should be discontinued; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor.
aFor patients with anxiety disorders use one-half the starting dose for depression. For patients older than 60 years, the therapeutic dose is reduced by one-half in the table above.
bThe following antidepressants should be avoided or used with great caution for the conditions listed because they often interact to increase the levels of medications commonly used for the condition23-25:

1. All SSRI/SNRI: (1) patients on anticoagulation; (2) patients using centrally acting appetite suppressants, eg, sibutramine, migraine taking 5HT agonists. Use mirtazapine or bupropion to treat depression in these
situations
2. Paroxetine: patients on medications for constipation, for ADHD
3. Venlafaxine: patients at risk for arrhythmia, hypertension, on anticoagulation
4. Duloxetine: patients with difficult to control hypertension, on anticoagulation
5. Fluoxetine: patients with ADHD on stimulants
Also, be aware of need for dosage reductions in patients with comorbid liver and renal disease.

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