Anti-Depressants / SSRIs

Antidepressants (SSRI’s are 1st and 2nd line treatment for Depression and Anxiety)
Generic Name Brand Name Dosage Forms Starting Dose Range Max Daily Dose Notes
Fluoxetine Prozac

10 mg, 20 mg, 40 mg, 60 mg

Liquid: 20 mg/5 ml

10-20 mg 80 mg

Longest half-life of SSRI’s translating into patients better tolerating missed doses and weans

Most studied SSRI in pediatrics

First line for child and adolescent MDD

Citalopram Celexa

10 mg, 20 mg, 40 mg

Liquid: 10 mg/5 ml

10-20 mg 60 mg

Dose-dependent QTc prolongation, should get EKG if titrating above 40 mg or when using with another medication that also increases QTc.

No pediatric FDA approval, considering using escitalopram first

Escitalopram Lexapro

5 mg, 10 mg, 20 mg

Liquid: 5 mg/5 ml

5-10 mg 20 mg More evidence in adolescent depression than pre-adolescent depression
Sertraline Zoloft

25 mg, 50 mg, 100 mg

Liquid: 20 mg/ml

25-50 mg 250 mg Youngest pediatric approval (≥6 for OCD)
Paroxetine Paxil

0 mg, 20 mg, 30 mg, 40 mg;

CR: 12.5 mg, 25 mg, 37.5 mg

Liquid: 10 mg/5ml

   

This medication has been associated with a higher risk of SI than other SSRI’s.

No pediatric approval

Would not recommend use in pediatric populations

Fluvoxamine Luvox

25 mg, 50 mg, 100 mg

CR: 100 mg, 150 mg

25 mg 200 mg (divided into BID when over 50 mg)

Short half-life/twice daily dosing of non-CR

CYP interactions and higher risk of interactions with other medications

 

See the Ohio Department of Medicaid Unified Preferred Drugs List for information about prescription coverage for children enrolled in Medicaid.

Medicaid Unified Preferred Drugs List

 

SSRI FDA Approval by Age Group (Empty boxes are not FDA approved for use)
  MDD OCD Panic Disorder Social Anxiety PTSD GAD
Citalopram ≥18          
Escitalopram ≥12         ≥18
Fluoxetine ≥8 ≥7        
Sertraline ≥18 ≥6 ≥18 ≥18 ≥18  
Duloxetine ≥18         ≥7
Paroxetine ≥18 ≥18 ≥18 ≥18 ≥18 ≥18
Fluvoxamine   ≥8        
Clomipramine   ≥10        

Typical SSRI side effects: consider mnemonic “BASS FISHING” (with “BASS” may be the most important side effects to warn about).

BASS: Behavioral Activation (restlessness, hyperkinesis, hyperactivity, agitation, disinhibition) or mania, Suicidal thoughts/behaviors (black box warning), Serotonin syndrome (triad of mental status changes, autonomic instability, neuromuscular abnormalities)

FISHING: Flu-like symptoms/asthenia and dizziness, Insomnia, Somnolence, Headaches, Interactions (drug-drug), Nervousness, GI effects (nausea, vomiting, diarrhea)

Not listed: sexual dysfunction (typically arousal), relevant to adolescent patients.

 
SSNRI's
Generic Name Brand Name Dosage Forms Starting Dose Max Dose Notes
Venlafaxine Effexor

25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg

XR 37.5 mg, 75 mg, 150 mg, 225 mg

   

Has high alpha-adrenergic activity, associated with multiple withdrawal symptoms This medication has been associated with a higher risk of SI than SSRI’s.

No pediatric FDA approval

Not recommended for use in pediatric populations

Desvenlafaxine Pristiq 25 mg, 50 mg, 100 mg 25 mg 100 mg

The major metabolite of venlafaxine, avoids some 2D6 metabolism Pharmacogenetic testing can be misleading, as this medication is always reported in the green (or “use as directed”) column, but there is no evidence for use in pediatric depression or anxiety.

No pediatric FDA approval

Duloxetine Cymbalta 20 mg, 30 mg, 60 mg 30 mg 120 mg

Approved for Pediatric GAD in 2014

Sometimes used for comorbid pain syndromes

 

Other Common Adjunctive Medications (Recommend using with caution or in consultation with psychiatry)
Generic Name Brand Name Dosage Forms Notes
Bupropion Wellbutrin

75 mg, 100 mg (BID)

SR 100 mg, 150 mg, 200 mg (BID)

XL 150 mg, 300 mg, 450 mg (daily)

XL 174 mg, 348 mg, 522 mg (daily)

Norepinephrine and Dopamine Reuptake Inhibitor

Reduces seizure threshold, highly dangerous in overdose

Can be used as adjunctive treatment to other medications

No pediatric approval

Mirtazapine Remeron

7.5 mg, 15 mg, 30 mg, 45 mg

Oral dissolving tablet 15 mg, 30 mg, 45 mg

No monoamine reuptake inhibition

No pediatric approval

Sometimes used off label for sleep or to help with depression

Sedation worse at lower doses due to more antihistamine effects

Trazodone Desyrel 50 mg, 100 mg, 150 mg, 300 mg

Serotonin modulator

Sometimes used off label for sleep

Metabolite has interaction with fluoxetine, resulting in decreased efficacy of fluoxetine

Amitriptyline Elavil 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg

Tricyclic anti-depressant (TCA) Associated with prolonged QTc and many other side effects, leading to poor tolerability

Exceptionally dangerous in overdose Used for migraines, pain, cyclic vomiting, occasionally adjunctive for mood

Need to monitor for serotonin syndrome if patient is on amitriptyline and other serotonin agents (SSRI’s, SNRI’s, etc.)