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Depression Treatment 2001 -

Talk by Dr. Ann Schack to Internal Medicine Dept. 7/25/01

Major Depression

Dx: For Dx need 5 Symptoms lasting > 2wks

• Sleep disturbance
• Interest in life decreases
• Guilty feelings
• Energy loss
• Concentration decreases
• Appetite affected
• Psychomotor retardation
• Suicidal Ideation

Rx for Sx:

• Sleep:  trazadone - low dose 25mg 2hrs before sleep
• Depression:  SSRI as Paxil, Prozac, Zoloft med.
• Anxiety + Depression:  Paxil
• Anxiety only:  klonopin 0.5mg (if not an alcoholic)

Dysthymia - lowgrade, long term depression

• Many somatic complaints
• Need > 2 Sx of major depression for 2 years
• Rx: SSRI

Adjustment Reaction: 2 necessary components:

• Distress
• Impairment

Generalized Anxiety Disorder

• Can't control worrying
• Excessive anxiety
• Rx with SSRI (zoloft, paxil), effexor. Buspar less effective

Panic Attacks

• Rx first with ativan then with SSRI (paxil, zoloft) + klonopin

Medication Doses

• Prozac: 10mg PC qd X 7-14d then increase to max of 80mg/d
• Paxil: 10mg HS, PC X 7d then increase to max 50mg/d. May switch to am PC if not sedating.
• Zoloft: Good for panic disorder, anxiety, depression. Tolerated in geriatrics. 100mg tab X ¼ qd X 1 wk then increase ½ tab/d to 50mg max for geriatrics and 100 mg/d everybody else. Max dose 200mg/d.
• Effexor: SSRI + norepi reuptake inhibitor. Don't get both effect until dose is > 225mg. Watch for HTN in higher doses. Use for GAD, anxiety, depression.
• Wellbutrin: Use with caution in seizure patients. No sexual side effects. Dose is 50mg-100mg bid to 100mg tid with max dose 450mg/d.
• Trazadone: 50mg X ½ 2 hrs. before retiring. Max dose is 100mg.
• Klonopin: Good for treating "nervous wrecks". Dose is 0.5mg X ½ bid, 1 tab. HS. + SSRI

Discontinuation Syndrome: "flu" like Sx when SSRI D/C'd. Less likely with prozac because of long ½ life

Antidepressant Medications:              

SSRI Class:
Celexa/Citalopram 2-40mg/day
Prozac/Fluoxetine 10-80 mg/day
Paxil/Paroxetine 10-60 mg/day
Zoloft/Sertraline 50-200 mg/day
Luvox/Fluvoxamine 50-300 mg/day

Tricyclics Class:
Elavil/Amitriptyline 50-300 mg/d
Norpramin/Desipramine 100-300 mg/d   
Sinequan/Doxepin 50-300 mg/d
Pamelor/Nortriptyline 50-200 mg/d
Tofranil/Imipramine 75-300 mg/d
Surmontil/Trimipramine 50-300 mg/d
Vivactil/Protriptyline 15-60 mg/dS
Anafranil/Clomipramine 25-250 mg/d
? Remeron/ Mirtazapine once/day tab

MAOI Class:
Nardil/Phenelzine 15-90 mg/d
Pamate/Tranylcypromine 20-50 mg/d

Mood Stabilizers:
Lithium 600-1800 mg/day;  T_1/2 = 24 hrs
St. John's Wort (Hypericum extract) 350 mg tid
(BMJ Dec.11,1999;319:1534 - Michael Philipp)

Other Class:
Asendin/Amoxapine 50-600 mg/d
Desyrel/Trazodone 150-600 mg/d
Effexor/Venlafaxine 75-375 mg/d
Ludiomil/Maprotiline 75-225 mg/d
Serzone/Nefazodone 200-600 mg/d
Wellbutrin/Bupropion 150-300 mg/d
Remeron/Mirtazapine 15-45 mg/d

Anti-anxiety Medications:

Benzodiazepines Class:
Xanax/Alprazolam 0.25-0.5-1 mg tid  T_1/2 = 6-27 hrs
Librium/Chlordiazepoxide 5-10-25 tab qid PO, IM or IV  T_1/2 = 24-48 hrs
Valium/Diazepam 2-5-10 mg qid  T_1/2 = 20-80 hrs
Serax/Oxazepam 10-15-30 mg cap qid  T_1/2 = 6-11 hrs
Ativan/Lorazepam 0.5-1-2-3 mg tid   T_1/2 = 12 hrs
Klonopin/Clonazepam 0.5-1-2 mg tid   T_1/2 = 18-50 hrs
Tranxene/Clorazepate  3.75-7.5-15 mg qid
Centrax/Prazepam 5-10-20 mg tab tid

Other Anti-anxiety Class:
Buspar/Buspirone 5-10-20 mg tid
Atarax/Vistaril/Hydroxyzine 10-25-50-100 mg qid prn
Meprobamate/Miltown/Equanil 200-400-600 mg qid

RopMazicon/Flumazenil 0.2 mg over 15 sec IV,
may repeat q 1 min x4 (max 1 mg)
Versed/Midazolam 1 mg over 2 min IV

     

Hypnotics - Sleeping Medications

Benzodiazepines Class:
Restoril/Temazepam 15-30 mg/d  T_1/2 = 3.5 - 18 hrs
Dalmane/Flurazepam 15-30 mg/d   T_1/2 = 2.3 hrs
Halcion/Triazolam 0.125 - 0.5 mg/d   T_1/2 = 1.5-5.5 hrs
Doral/Quazepam 7.5 - 15 mg/d   T_1/2 = 39 hrs
ProSom/Estazolam 1-2 mg/d   T_1/2 = 10-24 hrs

Barbiturates Class:
Seconal/Secobarbital 100-200 mg/d
Nembutal/Pentobarbital 100-200 mg/d
Amytal/Amobarbital 100-200 mg/d

Antihistamines Class:
Benadryl/Diphenhydramine 25-100 mg/d
Unisom/Doxylamine 25-100 mg/d

Other Class:
Sonata/ Zaleplon 5-10 mg cap hs
Chloral hydrate/Noctec 500-2000 mg/d  T_1/2 = 8-11 hrs
Ambien/Zolpidem 5-10 mg/d  T_1/2 = 2.6 hrs
Noludar/Methyprylon 200-400 mg/d
Placidyl/Ethchlorvynol 500-1000 mg/d

     

Antipsychotics Medications

Aliphatic: Thorazine/Chlorpromazine 50-2000 mg/d

Piperidine Class:
Mellaril/Thioridazine 50-800 mg/d
Serentil/Mesoridazine 100-400 mg/d

Piperazine Class:
Stelazine/Trifluoperazine 5-80 mg/d
Trilafon/Perphenazine 8-64 mg/d
Prolixin/Fluphenazine 2-40 mg/d PO or 12.5-75 mg IM q2wks

Butyrophenone Class:
Haldol/Haloperidol 2-100 mg/d PO or IM

Thioxanthene Class:
Navane/Thiothixene 5-60 mg/d

Benzisoxazole Class:
Zyprexa/Olanzapine 10-20 mg/d
Risperdal/Risperidone 4-6 mg/d

Dibenzodiazepine Class:
Clozaril/Clozapine 75-900 mg/d

Dibenzoxapine Class:
Loxitane/Loxapine 20-250 mg/d

Dihydroindolone Class:
Moban/Molindone 50-225 mg/d

Dibenzothiazepine Class:
Seroquel/Quetiapine 300-750 mg/d

Ref:
1998 Black Book of Psychotropic Dosing & Monitoring
by Alan F. Schatzberg, etc.  (Provided by Wyeth-Ayerst Lab)