What are some examples of medications for depression and their dose ranges?

Medications for Depression and Their Dose Ranges

The most effective medications for depression include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and other second-generation antidepressants, with dosage ranges tailored to maximize efficacy while minimizing side effects. 1

First-Line Antidepressant Options

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Citalopram (Celexa): 20-40 mg daily; therapeutic plasma concentration 30-130 ng/mL 1
• Escitalopram (Lexapro): 10-20 mg daily; therapeutic plasma concentration 15-80 ng/mL 1
• Fluoxetine (Prozac): 20-80 mg daily; initial dose 20 mg in the morning, with increases after several weeks if needed 2, 1
• Paroxetine (Paxil): 20-50 mg daily; therapeutic plasma concentration 70-120 ng/mL 1
• Sertraline (Zoloft): 50-200 mg daily; therapeutic plasma concentration 10-50 ng/mL 1
• Fluvoxamine: 150-300 mg daily; therapeutic plasma concentration 150-300 ng/mL 1

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Venlafaxine: 37.5-225 mg daily; therapeutic plasma concentration 195-400 ng/mL (including O-desmethylvenlafaxine) 1
• Duloxetine (Cymbalta): 40-120 mg daily 1
• Milnacipran (Savella): 12.5-200 mg daily 1

Other Second-Generation Antidepressants

• Bupropion SR (Wellbutrin SR): 100-400 mg daily; activating effect, may improve energy levels 1
• Mirtazapine (Remeron): 15-45 mg daily; therapeutic plasma concentration 40-80 ng/mL; promotes sleep, appetite, and weight gain 1
• Trazodone: 50-400 mg daily; therapeutic plasma concentration 650-1500 ng/mL; useful for insomnia 1

Tricyclic Antidepressants (TCAs)

• Amitriptyline: 25-300 mg daily 1
• Nortriptyline: 25-150 mg daily; therapeutic plasma concentration 70-170 ng/mL 1
• Desipramine: 100-300 mg daily; therapeutic plasma concentration 100-300 ng/mL 1
• Doxepin plus nordoxepin: therapeutic plasma concentration 50-150 ng/mL 1
• Imipramine plus desipramine: therapeutic plasma concentration 175-300 ng/mL 1
• Trimipramine: therapeutic plasma concentration 150-350 ng/mL 1

Medication Selection Considerations

Efficacy Considerations

• Second-generation antidepressants are generally considered first-line treatment due to their better adverse effect profiles 1
• SNRIs provide additional benefits for patients with comorbid pain disorders, with marginally superior remission rates compared to SSRIs (49% vs. 42%) 1
• Antidepressants show greater benefit in patients with severe depression compared to those with mild to moderate depression 1

Special Populations

• For elderly patients, start with approximately 50% of the adult starting dose 1
• Preferred agents for older adults include citalopram, escitalopram, bupropion, mirtazapine, venlafaxine, and sertraline due to favorable side effect profiles 1
• Avoid paroxetine (anticholinergic effects) and fluoxetine (risk of agitation) in older adults 1

Dosage Adjustments

• Reduce doses in patients with hepatic impairment for: bupropion, citalopram, duloxetine, fluoxetine, mirtazapine, nortriptyline, sertraline, trazodone, and venlafaxine 1
• Reduce doses in patients with renal impairment for: bupropion, duloxetine, milnacipran, paroxetine, and venlafaxine 1

Treatment Duration

• Continue treatment for 4-12 months after a first episode of major depressive disorder 1
• For recurrent depression, prolonged treatment may be beneficial 1
• The probability of recurrence increases with each episode: 50% after first episode, 70% after second episode, and 90% after third episode 1

Common Side Effects and Management

• SSRIs: gastrointestinal disturbances, headache, sedation, insomnia, sexual dysfunction 3
• SNRIs: similar to SSRIs but with potentially more noradrenergic side effects 4
• Mirtazapine: sedation, increased appetite, weight gain 1
• Bupropion: activating effects, insomnia, reduced seizure threshold 1
• TCAs: anticholinergic effects, sedation, orthostatic hypotension 1

Therapeutic Drug Monitoring

• Therapeutic drug monitoring is strongly recommended for TCAs like nortriptyline, desipramine, and imipramine 1
• For newer antidepressants, monitoring may be useful but is not as strongly recommended as for TCAs 1
• Monitoring is particularly valuable when using medications with established therapeutic ranges, in cases of treatment failure, or when drug interactions are suspected 4