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Warnick SJ Jr, Van Harrison R, Parikh SV, et al. Unipolar Depression [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2021 Feb.
| Generic Name (Trade Name) | Dosage | Key Clinical Information | 30-Day Costa | |
|---|---|---|---|---|
| Generic | Brand | |||
| Antidepressant Medications b, c, d (If patient is anxious, start lower and go slower.) | ||||
| Bupropion (Wellbutrin) | Start: IR-100 mg twice daily × 7 days, then increase to 100 mg three times daily SR-150 mg every morning × 3 days, then increase to 150 mg twice daily XL-150 mg every morning × 7 days, then increase to 300 mg every morning. Range: 300-450 mg/day. May divide dose with max dose of 300 mg at one time. | Novel mechanism Contraindicated in seizure disorder because it decreases seizure threshold Stimulating Less effective for treating anxiety disorders Second-line treatment for ADHD | $29 $15 $14 | $160 $104 $521 |
| Citalopram (Celexa) | Start: 20 mg daily × 7 days, then increase to 40 mg daily Max: 40 mg daily (Max: 20 mg daily if age ≥ 60 y, hepatic impairment, a CYP2C19 poor metabolizer, or taking a CYP2C19 inhibitor.) | Well-tolerated Minimal CYP450 interactions Good choice for anxious patients Caution: Dose dependent QTc prolongation | $8 | $320 |
| Duloxetine (Cymbalta) | Start: 30 mg daily × 7 days, then increase to 60 mg daily Range: 60-120 mg/day; divide dosing if patient prefers. | SNRI Treatment for neuropathic pain Need to monitor blood pressure Second-line treatment for ADHD Do not use in patients with substantial alcohol use or evidence of chronic liver disease Avoid use when creatinine clearance is less than 30 mL/min | $11 | $269 |
| Escitalopram (Lexapro) | Start: 5 mg daily × 7 days, then increase to 10 mg daily Range: 10-20 mg/day (~3 times as potent as citalopram) | Best-tolerated SSRI; minimal CYP450 interactions. Good choice for anxious patients | $6 | $372 |
| Fluoxetine (Prozac) | Start: 10 mg every morning × 7 days, then increase to 20 mg daily Range: 20-60 mg/day | More activating than other SSRIs Long half-life reduces withdrawal (t½ = 4–6 days) | $5 | $512 |
| Mirtazapine (Remeron) | Start: 15 mg at bedtime × 7 days, then increase to 30 mg at bedtime Range: 30-45 mg at bedtime | Unique mechanism Sedating and appetite promoting Neutropenia risk. Avoid in the immunosuppressed | $27 | $178 |
| Nortriptyline (Pamelor) | Start: 25 mg at bedtime × 7 days, then increase each week by 25 mg at bedtime to 75 mg at bedtime Range: 75–150 mg/day Max dose in elderly: 100 mg/day | TCA Sedating Used for neuropathic pain (at lower doses) Obtain baseline EKG Lethal in overdose | $12 | $1350 |
| Sertraline (Zoloft) | Start: 25 mg every morning × 7 days, then increase to 50 mg daily Range: 50-200 mg/day | SSRI Limited CYP450 interactions Mildly activating First-line during pregnancy and when postpartum if breastfeeding | $6 | $361 |
| Venlafaxine (Effexor) | Start: IR-37.5 mg twice daily × 7 days, then increase to 75 mg twice daily ER-75 mg every morning × 7 days then increase to 150 every morning Range: 150-375 mg/day | SNRI More agitation and GI side effects than SSRIs Used for neuropathic pain at 225 mg/day and above Need to monitor blood pressure Significant withdrawal syndrome | $10-12 | $521 |
| Vortioxetine (Trintellix) | Start:10 mg at bedtime × 2 weeks, then increase if necessary to 15 or 20 mg daily Range: 10-20 mg/day | May have pro-cognitive properties. | N/A | $419 |
| Anti-Manic Medication (Augmentation for Depression) | ||||
| Lithium (Lithobid) | Augmentation treatment for MDD. Start: 300 mg twice daily or 600 mg at bedtime Target serum concentration: 0.6–1.0 meq/L. (specifically for augmentation of MDD) Available in ER form dosed once daily (usually at bedtime). Plasma levels are related to renal clearance | Avoid in renal failure. Monitor creatinine and electrolytes. | $18 | $810 |
| Antipsychotics and Mood Stabilizerse | ||||
| Aripiprazole (Abilify) | MDD augmentation. Start: 2 mg/day; adjust daily dose every 1+ weeks by 1–2 mg Range: 2–5 mg/day, occasionally higher. | Modest side effects at doses of 2–4 mg/day, but advisable to monitor weight and metabolic parameters. Significant side effects at doses of 10 mg/day and higher. | $11 | $963 |
| Brexpiprazole (Rexulti) | MDD augmentation. Start: 0.5–1 mg/day, increase to 2 mg/day if necessary after 1 week. | Modest side effects up to 1 mg/day, but advisable to monitor weight and metabolic parameters. | N/A | $1258 |
| Quetiapine (Seroquel) | MDD augmentation. Start: 50 mg at bedtime. May increase dose every 3–7 days until a daily dose of 150 mg is reached Initial target: 150 mg at bedtime. Range: 150–300 mg/day. | Modest side effects besides sedation up to 150 mg/day, with weight and metabolic monitoring advisable. | $12 | $534 |
| Risperidone (Risperdal) | MDD augmentation. Start: 0.5–1 mg at bedtime, increase each week by 0.5–1 mg/day. Range: 1–2 mg/day. | Modest side effects up to 1 mg/day, but advisable to monitor weight and metabolic parameters. Monitor prolactin at doses above 1 mg/day. | $7 | $617 |
Note: Adapted from Commonly Prescribed Psychotropic Medications developed by Stephen Thilke, MD, MPH and Alex Thompson, MD, MPH in 2008. Subsequent revisions by David Harrison, MD, PhD and Anna Ratzliff, MD, PhD, August 2015. Revision by Joseph Cerimele MD, MPH, May 2018. AIMS (Advancing Integrated Mental Health Solutions) Center, University of Washington, Seattle, Washington.
Key: ADHD=attention deficit hyperactivity disorder; IR=immediate release; MDD=major depressive disorder; SNRI=serotonin-norepinephrine reuptake inhibitor; SSRI=selective serotonin reuptake inhibitor; SR=12-hour sustained release; TCA=tricyclic antidepressant; XL=24-hour extended release.
Cost = Average Wholesale Price minus 10%. AWP from Lexicomp Online 11/19. For generic drugs, Maximum Allowable Cost plus $3 from BCBS of Michigan MAC List, 11/19.
Antidepressant Medications warnings and precautions: 1) Potential increased suicidality in first few months, 2) Long term weight gain possible (except venlafaxine and bupropion), 3) Sexual side effects are common (except bupropion and mirtazapine), 4) Withdrawal symptoms can occur with abrupt cessation (especially with SSRIs and SNRIs), 5) Increased risk of bleeding with SSRIs and SNRIs (especially in combo with NSAIDs), 6) Risk for serotonin syndrome (except bupropion), when combined with medications or drugs affecting serotonin metabolism, 7) Hyponatremia sometimes occurs with SSRIs and SNRIs in older adults, 8) See Table 5 for psychiatric comorbid conditions with SSRIs.
Paroxetine (Paxil): formerly was popular, but avoid as it has significant withdrawal syndrome, drug interactions, and risk in pregnancy.
Monoamine oxidase inhibitors (MAOIs) are recommended as treatment in patients with treatment resistant depression. Due to their side effect profile (serotonin syndrome, hypertensive crisis) we recommend they be prescribed by a specialist or PCP with knowledge of which MAOIs require dietary modifications.
Antipsychotics and mood stabilizer warnings and precautions:
From: Unipolar Depression
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