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 FDA approved for GAD ages 7+ |
| 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 |
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| 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 |
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Antidepressants (SSRI’s are 1st and 2nd line treatment for Depression and Anxiety)
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 | ≥7 | ||||
| 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, 112.5 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 first-line use in pediatric populations |
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| 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 |
FDA approved for pediatric GAD but may be less effective than escitalopram 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 sometimes worse at lower doses due to more antihistamine effects |
| Trazodone | Desyrel | 50 mg, 100 mg, 150 mg, 300 mg |
Serotonin modulator Usually 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.) |