Psychiatric Medication Guide F O R : N E O N P R I M A R Y H E A L T H C A R E P R O V I D E R S B Y : M I C H E L L E R O M E R O, D O M A Y, 2 0 1 3
Anti-depressants TCA s & MAOI s (Tricyclic Antidepressants & Mono- Amine Oxidase Inhibitors) old, lots of side effects/not well tolerated, rarely used SSRI s (Selective Serotonin Reuptake Inhibitors) first line SNRI s (Serotonin Norepinephrine Reuptake Inhibitors) second line, after failing 2 SSRI trials adjunctive Novel second line, after failing 2 SSRI trials adjunctive
SSRI s: class side effects Nausea & decrease in appetite for 2 weeks after initiating or increasing dose. Increase in restlessness for 2 weeks after initiating or increasing dose. Take in AM; may interrupt sleep cycle. Increased vividness of dreams. Sexual side effects: prolonged time to ejaculation in males. some also complain of a decrease in libido
SSRI s: black box warning Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders: consider risk prior to prescribing.
SSRI s: Fluoxetine (Prozac) Approval: Major Depressive d/o; Obsessive-Compulsive d/o; Bulimia; Premenstrual Dysphoric d/o; Panic d/o Also used for: Generalized Anxiety d/o; Post-traumatic Stress d/o Pregnancy: class C; generally felt safe for use in pregnancy do NOT use in lactation Forms: Capsule: 10mg, 20mg, 40mg Tablet: 30mg, 60mg ($$$) Liquid: 20mg/5ml
SSRI s: Fluoxetine (Prozac) Adult dosing: 20mg 80mg Start with 20mg May increase dose every 4-6 weeks by 10-20mg Higher doses (60-80mg) generally more effective for anxiety than lower doses On NEON Formulary Capsules can be found as $4.00 generic at many pharmacies
SSRI s: Sertraline (Zoloft) Approval: Major Depressive d/o; Obsessive- Compulsive d/o; Social Anxiety d/o; Panic d/o; Posttraumatic Stress d/o; Premenstrual Dysphoric d/o Also used for: Generalized Anxiety d/o; Bulimia Pregnancy: class C; generally felt safe for use in pregnancy generally thought safe for use in lactation Forms: Tablet: 25mg, 50mg, 100mg Liquid: 20mg/ml
SSRI s: Sertraline (Zoloft) Adult dosing: 50mg - 200mg Start at 50mg May increase dose every 4-6 weeks by 25-50mg Higher doses (100-200mg) generally more effective for anxiety than lower doses On NEON Formulary $4.00 medication at Marc s Pharmacy
SSRI s: Paroxetine (Paxil) Approval: Major Depressive d/o; Panic d/o; Social Phobia; Generalized Anxiety d/o; Premenstrual Dysphoric d/o; Obsessive-Compulsive d/o; Posttraumatic Stress d/o Pregnancy: class D; do not use; may cause congenital malformations do NOT use in lactation Forms: Tablet: 10mg, 20mg, 30mg, 40mg CR, tablet: 12.5mg, 25mg, 37.5mg Oral Suspension: 10mg/5ml
SSRI s: Paroxetine (Paxil) High side effect profile: generally not well tolerated Adult dosing: 20mg 60mg CR: 25mg 75mg May increase every 4-6 weeks by 10mg (CR: 12.5mg) Higher dosing generally more effective for anxiety than lower dosing Regular Paroxetine may be on some $4.00 formularies
SSRI s: Citalopram (Celexa) Approval: Major Depressive d/o Also used in: Generalized Anxiety d/o, Obsessive- Compulsive d/o; Panic d/o; Social Anxiety d/o; Posttraumatic Stress d/o; Dementia Pregnancy: class C; if pt conceived and is stable while taking medication there is no indication to change may use in lactation Forms: Tablet: 10mg, 20mg, 40mg Oral Solution: 10mg/5ml
SSRI s: Citalopram (Celexa) Adult dosing: 20-40mg Start 20mg May increase dose every 4-6 weeks by 10-20mg Higher doses (30-40mg) generally more effective for anxiety than lower doses Can no longer titrate over 40mg due to increased risk for QTc prolongation without monitoring EKG Can be found as $4.00 generic at many pharmacies
SSRI s: Escitalopram (Lexapro) Approval: Major Depressive d/o; Generalized Anxiety d/o Also used for: Obsessive-Compulsive d/o; Panic d/o; Social Anxiety d/o; Post-traumatic Stress d/o Pregnancy: class C safety unknown in lactation Forms: Tablets: 5mg, 10mg, 20mg Liquid: 5mg/5ml
SSRI s: Escitalopram (Lexapro) Generally thought to have low side effect profile and work more quickly than the other SSRI s Adult dosing: 10mg 20mg Start 10mg May increase dose every 2-4 weeks by 5-10mg Higher doses (15-20mg) generally more effective for anxiety than lower doses $$$
SNRI s: class side effects Nausea & decreased appetite for 2 weeks after initiating and increasing dose. Increase in restless for 2 weeks after initiating or increasing dose. Take in AM; may interrupt sleep cycle. Increase vividness of dreams. Sexual side effects: prolonged time to ejaculation in males. Some also complain of a decrease in libido.
SNRI s: black box warning Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders: consider risk prior to prescribing.
SNRI s: Venlafaxine (Effexor) Approval: Major Depressive d/o; Generalized Anxiety d/o; Social Phobia; Panic d/o Also used for: Obsessive-Compulsive d/o; Posttraumatic Stress d/o Pregnancy: class C do NOT use in lactation Forms: Tablet: 25mg, 37.5mg, 50mg, 75mg, 100mg Capsule: 37.5mg, 75mg, 150mg ER, Capsule: 37.5mg, 75mg, 150mg
SNRI s: Venlafaxine (Effexor) Dose dependent HTN & Significant withdrawal symptoms Adult dosing: Immediate Release (bid or tid dosing): 75mg 375mg per day start 37.5mg PO BID; increase by 37.5mg PO BID Extended Release: 75mg 225mg start 37.5mg for 1 week; then 75mg; increase by 37.5-75mg May increase every 4-6 weeks Higher dosing generally more effective for anxiety than lower dosing Immediate release 50 & 75mg tablets at NEON Pharmacy
SNRI s: Duloxetine (Cymbalta) Approval: Major Depressive d/o; Generalized Anxiety d/o; Neuropathic Pain associated with Diabetes; Fibromyalgia Also used for: Obsessive-Compulsive d/o; Social Anxiety d/o; Panic d/o; Post-traumatic Stress d/o; Neuropathic Pain Pregnancy: class C do NOT use in lactation Forms: Capsules: 20mg, 30mg, 60mg
SNRI s: Duloxetine (Cymbalta) Avoid if LFT s elevated Adult dosing: 30mg 120mg Start 30mg May increase every 4-6 weeks by 30mg Higher doses (60-90mg) generally more effective for anxiety than lower doses $$$
SNRI s: Desvenlafaxine (Pristiq) Approval: Major Depressive d/o Also used for: Generalized Anxiety d/o; Social Anxiety d/o; Panic d/o; Obsessive-Compulsive d/o; Post-traumatic Stress d/0 Pregnancy: class C do NOT use in lactation Forms: Tablet: 50mg, 100mg
SNRI s: Desvenlafaxine (Pristiq) Adult dosing: 50mg 100mg Start 50mg May increase to 100mg after 4-6 weeks Dosing higher than 50mg generally no more effective $$$
Novel: Buproprion (Wellbutrin) Side effects: May have a headache for 2 weeks after initiating or increasing dose. Take in AM; if BID/TID dosing take last dose at dinnertime Decreased appetite Increased energy Do not use if patient already pre-disposed to Seizure d/o Black box warning: Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders: consider risk prior to prescribing.
Novel: Buproprion (Wellbutrin) Approval: Major Depressive d/o; Seasonal Affective d/o; Adjunct in Smoking Cessation Also used for: Attention Deficit Hyperactivity d/o; Sexual side-effects of SSRI s/snri s Pregnancy: class C do NOT use in lactation Forms: tablets (cannot be cut/split) Immediate Release: 75mg, 100mg Sustained Release: 100mg, 150mg, 200mg Extended Release: 150mg, 300mg
Novel: Buproprion (Wellbutrin) Safer in Bipolar depression; less likely to induce mania. Adult dosing: IR (TID dosing): 100mg PO TID; max 450mg total per day SR (BID dosing): 150mg PO BID; max 400mg total per day XR (once daily dosing): 150mg 450mg; start 150mg PO qam May increase every 4-6 weeks 150mg XR on NEON Formulary
Novel: Mirtazapine (Remeron) Side effects: Take at bedtime Increase in appetite: will decrease with increase in dose Sleepiness: will decrease with increase in dose Black box warning: Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders: consider risk prior to prescribing.
Novel: Mirtazapine (Remeron) Approval: Major Depressive d/o Also used for: Generalized Anxiety d/o Pregnancy: class C do NOT use in lactation Forms: Tablets: 15mg, 30mg, 45mg Oral Dissolvable Tablets: 15mg, 30mg, 45mg
Novel: Mirtazapine (Remeron) Side effects of being sleepy and hungry decrease with higher dosing Adult dosing: 15mg 60mg Start: 15mg May increase every 4-6 weeks by 15mg Higher dosing (45-60mg) generally more effective for anxiety than lower doses
Common Mood Stabilizers Lithium Valproic Acid (Depakote) Lamotrigine (Lamictal)
Lithium Approval: Bipolar d/o; treatment of Bipolar Mania; Bipolar Maintenance Also used for: management of Suicidality; adjunctive management for Major Depressive d/o Pregnancy: class D; Ebstein s anomaly; safer than Depakote do NOT use in lactation Forms: Capsules: 150mg, 300mg, 600mg ER Tablets: 300mg, 450mg Liquid: 300mg/5ml
Lithium Common Side Effects: Tremor, Polyuria, Polydipsia, Weight Gain, Alopecia, Fatigue Black Box Warning: Lithium toxicity is closely related to serum concentrations and can occur at therapeutic dosing: serum lithium determinations are required to monitor therap. Normal fluid and salt intake must be maintained during therapy. Lithium Toxicity: Nausea, Vomiting, Diarrhea, Dizziness, Weakness, Hyperreflexia, Slurred Speech Watch out for Dehydration & Avoid NSAID use
Lithium Monitoring: Renal Functions Thyroid Functions Lithium Level: therapeutic 0.6-1.2 Check initial level 4-5 days after initiation Re-check every 3 months Adult Dosing: Regular Release: 300mg - 2400mg divided BID-TID Start 600mg (300mg PO BID) Usual Effective dose: 900-1200mg May increase by 300mg every week as needed
Lithium Adult Dosing: Extended Release: 300mg 1800mg divided BID-TID Start 900mg (450mg PO BID) Usual effective dose: 900-1200mg May increase by 300mg every week as needed Immediate release 300mg capsules available on the NEON Formulary. Generally a cheap generic option at many pharmacies.
Valproic Acid (Depakote) Approval: Mania associated with Bipolar d/o; Migraine Prophylaxis; Seizure d/o Also used for: Bipolar Maintenance; Impulse Control d/o Pregnancy: class D; may cause teratogenic effects such as neural tube defects Okay for use in lactation Forms: Tablets (cannot be cut/split) Immediate Release: 125mg, 250mg, 500mg Extended Release: 250mg, 500mg Sprinkles (capsule): 125mg Liquid: 250mg/5ml
Valproic Acid (Depakote) Common Side Effects: Diarrhea; Weight Gain; Somnolence; Nausea Black Box Warning: Hepatic failure resulting in fatalities has occurred in patients; children under 2 years of age are at considerable risk. Depakote Toxicity: Nausea, Vomiting, Decreased level of Concsiousness, Confusion
Valproic Acid (Depakote) Monitoring: Liver Functions CBC Valproic Acid Level: therapeutic 85-125 Check initial level 3-4 days after starting medication Recheck all lab levels every 6 months Adult Dosing: 250mg 2500mg daily Usual effective dose: 1500-2000mg Start 1000mg May increase by 250-500mg every week as needed If switching from regular release to extended release increase total dose by 20%
Valproic Acid (Depakote) Regular release 500mg tablets and Extended release 250mg & 500mg tablets available on the NEON Formulary. Regular release generally a cheap generic at many pharmacies.
Lamotrigine (Lamictal) Approval: maintenance treatment of Bipolar I in adults Also used for: maintenance of Bipolar II; Bipolar depression Pregnancy: class C; watch serum concentrations and increase folic acid intake (5mg daily) do NOT use in lactation Forms: Tablets: 25mg, 100mg, 150mg, 200mg Easy to cut/split
Lamotrigine (Lamictal) Generally well tolerated Black Box Warning: Severe and potentially life-threatening skin rashes requiring hospitalization have been reported; risk may be increased by co-administration with valproic acide, higher than recommended started doses, and rapid dose titration.
Lamotrigine (Lamictal) Adult Dosing: 200mg (100mg if co-administered with Valproic Acid) Titration: 25mg daily for 2 weeks; 50mg daily for 2 weeks; 100mg daily for 1 week, 150mg daily for 1 week, then 200mg Titration with Valproic Acid: 25mg every other day for 2 weeks, 25mg daily for 2 weeks, 50mg daily for 2 weeks, 75mg daily for 2 weeks, then 100mg If patient misses dose for 2-3 days, generally okay to resume regular dosing, if misses dose for longer need to restart titration, but may titrate weekly (unless in combination with valproic acid).
Lamotrigine (Lamictal) Some doses available on NEON Formulary. Generic ranges from $30-60/month as most pharmacies.
Anti-psychotics Typical/First Generation Monitor AIMS (Abnormal Involuntary Movement Scale) for Extrapyramidal Symptoms (EPS), Tardive Dyskinesia (TD), and Dystonic Reactions. Atypical/Second Generation Monitor fasting lipids, fasting glucose/hba1c, BMI/waist circumference, and weight at initiation and then at 3 months, 6 months, 12 months, annually. If > 5% weight gain, consider changing to a different medication.
Anti-psychotics Black Box Warning: Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death compared with placebo.
Typical/First Generation: Haldol (Haloperidol) Approval: Schizophrenia; Tourette s syndrome; Severe Behavioral Problems in Children Also used for: Bipolar d/o Pregnancy: class C; generally thought safe for use during pregnancy at lowest effective dose do NOT use in lactation Forms: Tablets: 0.5mg, 1mg, 2mg, 5mg, 10mg, 20mg Decanoate (IM): 100-200mg IM q4wks
Typical/First Generation: Haloperidol (Haldol) Common Side Effects: Mild Sedation EPS/TD: manage with Benztropine (Cogentin) or Benadryl Acute Dystonic Reaction: mange with Benadryl Neuroleptic Malignant Syndrome Adult Dosing: 1mg 100mg BID-TID Average dosing: 10-60mg BID-TID Starting dose dependent on severity of symptoms May increase by up to 5-10mg every 5 days as needed
Typical/First Generation: Haloperidol (Haldol) 1mg tablets available on the NEON Formulary. Can also be found on $4.00 formularies at several pharmacies. Old, cheap generic medication.
Atypical/Second Generation Olanzapine (Zyprexa) Risperidone (Risperdal) Quetiapine (Seroquel/Seroquel XR) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega)
Olanzapine (Zyprexa) Approval: Schizophrenia; Acute Mixed Episodes; Maintenance of Bipolar d/o; Acute Agitation Pregnancy: class C; occasionally used do NOT use in lactation Forms: Tablets: 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg Oral Dissolvable Tablets: 5mg, 10mg, 15mg, 20mg
Olanzapine (Zyprexa) Adult Dosing: 2.5mg 20mg Start 2.5-5mg qhs May increase by 2.5-5mg every 5 days as needed Generally sedating. Generally contributes to a lot of weight gain/increase in appetite.
Risperidone (Risperdal) Approval: Schizophrenia; Acute Mania or Mixed episodes associated with Bipolar I; Irritability or Aggression associated with Autistic d/o Consta: maintenance of Bipolar I Pregnancy: class C do NOT use in lactation Forms: Tablets: 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg Oral Dissolvable Tablets: 0.5mg, 1mg, 2mg, 3mg, 4mg Liquid Solution: 1mg/1ml Consta IM Injection : 12.5mg 50mg q2wks
Risperidone (Risperdal) Adult Dosing: 1-8mg Usual effective dosing: 2-6mg Start 0.5-1mg daily Increase by 0.5-1mg weekly as needed Monitor Prolactin: most likely to cause galactorrhea (lactation) in females and males. Some tablet dosages available on the NEON Formulary.
Quetiapine (Seroquel) Approval: Schizophrenia; Acute Manic Episodes; Maintenance of Bipolar I d/o in combination; Depression associated with Bipolar d/o; Adjunctive management of Unipolar Depression Additional Black Box Warnings: Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk before prescribing. Quetiapine is no FDA approved for use in children. Quetiapine is approved for the treatment of bipolar depression.
Quetiapine (Seroquel) Pregnancy: class C do NOT use in lactation Forms: Tablets: 25mg, 50mg, 100mg, 200mg, 300mg, 400mg XR, Tablets: 50mg, 150mg, 200mg, 300mg, 400mg Adult Dosing: 50mg 800mg daily Regular Release: usual effective dose 200-400mg daily Divided, BID, dosing May increase by 25-50mg every week as needed
Quetiapine (Seroquel) Adult Dosing: Extended release: usual effective dose 300-600mg Once daily dosing: should be in the evening, about 12 hours before wanting to wake up the next morning. Start 150-300mg Increase by 150-300mg every week as needed Generally sedating. Generally contributes to weight gain.
Ziprasidone (Geodon) Approval: Schizophrenia; Acute Manic or Mixed episodes with or without psychosis; Maintenance of Bipolar d/o as adjunct; Acute Agitation in Schizophrenia Also used for: adjunctive management of Major Depressive d/o Pregnancy: class C do NOT use in lactation Forms: Capsules: 20mg, 40mg, 60mg, 80mg
Ziprasidone (Geodon) Adult Dosing: 40mg 160mg (BID dosing) Start 20mg PO BID Increase by 20-40mg every week as needed Take with food Does not generally lead to weight gain and may actually contribute to weight loss. Monitor QTc (if >450-500 don t start; monitor for overall change in QTc); monitor BP, pulse, serum potassium, and serum magnesium.
Aripiprazole (Abilify) Approval: Acute and Maintenance treatment of Schizophrenia; Stabilization, Maintenance, and Adjunct in Bipolar d/o; Adjunct in Major Depressive d/o; Irritability associated with Autistic d/o Additional Black Box Warnings: Anti-depressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk before prescribing. Aripiprazole is not FDA approved for adjunctive treatment of depression in children.
Aripiprazole (Abilify) Pregnancy: class C do NOT use in lactation Forms: Tablets: 2mg, 5mg, 10mg, 15mg, 20mg, 30mg Oral Dissolvable Tablets: 10mg, 15mg Liquid: 1mg/1ml Adult Dosing: 2mg 30mg Lower dosing (2-10mg) for depression Mid-range dosing (10-20mg) for bipolar Upper range dosing (15-30mg) for schizophrenia
Aripiprazole (Abilify) Adult Dosing: Starting dose depends on disorder and severity of presentation. May increase by 2-5mg every week as needed. Generally does not lead to weight gain or sedation. Watch for Akasthesia (inner restlessness). Treat with Propranolol
Paliperidone (Invega) Approval: Acute and Maintenance Treatment of Schizophrenia and Schizoaffective d/o Also used for: Bipolar d/o Pregnancy: class C do NOT use in lactation Forms: Capsules: 1.5mg, 3mg, 6mg, 9mg Sustenna (IM): 234mg IM x 1; then 156mg IM x 1 in 7 days; then 117mg IM q4wks
Paliperidone (Invega) Adult Dosing: 3mg 12mg Start 6mg May increase by 3mg every week as needed Monitor Prolactin Enantiomer of Risperidone May contribute to galactorrhea (lactation)
Anti-anxiety Buspirone (Buspar) SSRI s SNRI s Mirtazapine (Remeron) Benzodiazepines
Buspirone (Buspar) Approval: Generalized Anxiety d/o Also used for: Social Anxiety d/o Pregnancy: class B do NOT use in lactation Forms: Tablets (easy to cut/split): 5mg, 7.5mg, 10mg, 15mg, 30mg
Buspirone (Buspar) Adult Dosing: 10mg 60mg per day Divided dosing: BID TID Start 10mg PO BID Increase by 5-10mg per week as needed May be slightly sedating, but generally well tolerated. No risk of dependency/abuse.
Benzodiazepines: Clonazepam (Klonopin) Approval: Panic d/o Generally BID dosing Not necessary to dose more frequently than TID Start 0.5mg PO BID technically no upper limit Taper slowly Pregnancy: class D do NOT use in lactation Monitor for dependency/abuse frequently monitor OARRS
Benzodiazepines: Lorazepam (Ativan) Approval: Anxiety disorders and Anxiety associated with Depression Generally TID dosing Can be up to every 4 hours; generally lasts 6-8 hours Start 0.5mg PO TID Technically no upper limit Taper slowly Pregnancy: class D, but sometimes used in limited dosing and not close to delivery do NOT use in lactation
Benzodiazepines: Lorazepam (Ativan) Do not use in hepatic failure. Monitor for dependency/abuse. frequently monitor OARRS
Benzodiazepines: Alprazolam (Xanax) Approval: Generalized Anxiety d/o; Panic d/o; Anxiety associated with Depression May need to be dosed 4 times a day Generally lasting only 22-4 hours with pretty immediate onset of action. Quick onset and short duration of action increases the likelihood of dependence/abuse. Start 0.5mg PO TID Doses over 4mg daily not recommended Technically no upper limit
Benzodiazepines: Alprazolam (Xanax) Taper slowly Pregnancy: class D do NOT use in lactation Monitor for dependency/abuse frequently monitor OARRS
Others Trazodone: frequently used for sleep Dose 50mg 200mg PO qhs Hydroxyzine: frequently used for anxiety and/or sleep Dose: 12.5mg 50mg PO TID & qhs Propranolol: frequently used for anxiety, especially performance based anxiety Dose: 10mg 20mg PO TID Prazosin: frequently used for nightmares in Posttraumatic Stress d/o Dose: 1mg 2mg PO qhs Gabapentin: frequently used as add-on management for anxiety or mood-stabilization Dose: 100mg 300mg PO TID with higher bedtime dosing for sleep