Antidepressants
Drug Class | Specific Medication | Selected Precautions* |
|---|---|---|
Selective Serotonin Reuptake Inhibitors (SSRIs) | Cause discontinuation symptoms† if stopped abruptly (less likely with fluoxetine) | |
Citalopram | Lower potential for drug interactions because it has less effect on CYP450 isoenzymes Risk of QT-interval prolongation that limits doses to ≤ 40 mg/day | |
Fluoxetine | Has very long half-life Less likely to cause discontinuation symptoms† The only antidepressant proven effective in children | |
Fluvoxamine | Can cause clinically significant elevation of theophylline, warfarin, and clozapine blood levels Has potential for interactions between its active metabolites and HCAs, carbamazepine, antipsychotics, or type 1C antiarrhythmics Has CYP450 profile similar to fluoxetine | |
Paroxetine | Has potential for interactions between its active metabolites and HCAs, carbamazepine, antipsychotics, or type 1C antiarrhythmics Has CYP450 profile similar to fluoxetine Of SSRIs, may cause the most weight gain | |
Sertraline | Of SSRIs, has highest incidence of loose stools | |
Vilazodone | May increase risk of bleeding if taken with aspirin, other NSAIDs, or other drugs that affect coagulation Should not be stopped abruptly; reduce dose gradually | |
Serotonin modulators (5-HT2 blockers) | Cause discontinuation symptoms† if stopped abruptly | |
Mirtazapine | Causes weight gain and sedation Has fewer sexual adverse effects than SSRIs and SNRIs | |
Trazodone | May cause priapism and sedation May cause orthostatic hypotension | |
Serotonin-norepinephrine reuptake inhibitors (SNRIs) | — | |
— | Desvenlafaxine | May increase BP or HR (control BP before initiating the medication and monitor BP and HR while patients are on it) |
Duloxetine | Modest dose-dependent increase in systolic and diastolic BP May cause mild urinary hesitancy in males Less potential for drug interactions because it has less effect on CYP450 isoenzymes | |
Levomilnacipran | May increase BP or HR (control BP before initiating the medication and monitor BP and HR while patients are on it) May increase risk of bleeding if it is taken with aspirin, other NSAIDs, or anticoagulants Can affect urinary hesitation or retention (caution required in patients with obstructive urinary disorders; stop it if symptoms develop) | |
Milnaciprin | Similar to levomilnacipran Nausea is most common side effect | |
Venlafaxine | Modest dose-dependent increase in diastolic BP Dual norepinephrine and 5-HT reuptake effect at approximately 150 mg Rarely, increase in systolic BP (not dose-dependent) If stopped, should be tapered slowly Less potential for drug interactions because it has less effect on CYP450 isoenzymes | |
Vortioxetine | May increase risk of bleeding if taken with aspirin, other NSAIDs, or other medications that affect coagulation or bleeding | |
Norepinephrine-dopamine reuptake inhibitor | — | |
Bupropion | Contraindicated in patients who have bulimia or who are seizure-prone May interact with HCAs, increasing the risk of seizures May cause dose-dependent recent memory loss | |
N-methyl D-aspartate (NMDA) antagonist/sigma-1 agonist | — | |
Bupropion/dextromethorphan | Common side effects include dizziness, headache, diarrhea, sleepiness, dry mouth, sexual dysfunction, hyperhydrosis Serious side effects include seizures, mania, acute angle-closure glaucoma, elevated blood pressure, and serotonin syndrome | |
Heterocyclics | Contraindicated in patients with coronary artery disease, certain arrhythmias, angle-closure glaucoma, benign prostatic hyperplasia, or esophageal hiatus hernia Can cause orthostatic hypotension leading to falls and fractures, potentiate the effect of alcohol, and raise the blood level of antipsychotics Cause discontinuation symptoms† if stopped abruptly With significant overdose, potentially lethal | |
Amitriptyline | Causes weight gain | |
Amoxapine | Can have extrapyramidal adverse effects | |
Clomipramine | Lowers seizure threshold at doses of > 250 mg/day | |
Desipramine | Metabolized only via CYP2D6 isoenzyme: Medications that inhibit this enzyme markedly increase plasma levels | |
Doxepin | Causes weight gain | |
Imipramine | May cause excessive sweating and nightmares | |
Maprotiline | Increased risk of seizures with rapid dose escalation at high doses | |
Nortriptyline | Has long half-life (74 hours) | |
Protriptyline | Has long half-life (74 hours) | |
Trimipramine | Causes weight gain | |
Monoamine oxidase (MAO) inhibitors | Serotonin syndrome possible when taken with an SSRI Hypertensive crisis possible when taken with other antidepressants, sympathomimetic or other selected medications, or certain foods and beverages With significant overdose, potentially lethal | |
Isocarboxazid | Causes orthostatic hypotension | |
Phenelzine | Causes orthostatic hypotension | |
Selegiline, transdermal | Can cause application site reactions and insomnia | |
Tranylcypromine | Causes orthostatic hypotension Has amphetamine-type stimulant effects and modest abuse potential | |
Psychostimulants | ||
Dextroamphetamine Methylphenidate | Sometimes used as adjunctive therapy in treatment-resistant depression | |
Melatonergic antidepressant | ||
Agomelatine (5-HT2C receptor antagonist) | Should be stopped immediately if symptoms or signs of potential liver injury develop or if serum aminotransferases increase to> 3 times the upper limit of normal Not available in the United States | |
Ketamine and esketamine | ||
Ketamine | Nausea, dizziness, headache, increased blood pressure, increased heart rate, anxiety, feeling of detachment, addiction Ketamine (used in lower doses than used for anesthesia) is used in combination with oral antidepressants for treatment-resistant depression. Ketamine can be given intravenously, orally, or as a nasal spray. Ketamine is sometimes used as a drug of abuse. | |
Esketamine | Nausea, dizziness, headache, feeling of detachment Esketamine is used in combination with other oral antidepressants for treatment-resistant depression. Esketamine is available as a nasal spray. | |
* Antidepressant use may increase the risk of suicidal thinking and behavior in pediatric and young adult patients with major depressive disorder and other psychiatric disorders. Refer to a drug information resource for more detailed information regarding dosing, adverse reactions, and other safety considerations. † Discontinuation symptoms include nausea, chills, muscle aches, dizziness, anxiety, irritability, insomnia, and fatigue. BP = blood pressure; CYP = cytochrome P450 system; HCAs = heterocyclic antidepressants; HR = heart rate; 5-HT = 5-hydroxytryptamine (serotonin); NSAID = nonsteroidal anti-inflammatory. | ||