Clinical Review & Education

From The Medical Letter on Drugs and Therapeutics

Drugs for Depression

“…it felt like I was living in a fog and was always sleepy. In high
school, in fact, a lot of people thought I was on drugs or some-
thing because I was really out
of it. I know when I’m really de-
Author Audio Interview
pressed because it feels like
a sort of membrane, almost like gelatin, enclosing me.”1
This statement from a patient who has depression captures
how disabling the condition can be. It is common, with a lifetime
prevalence of 19% and can be very disabling.2 Every clinician is
likely to encounter patients with depression and should be famil-
iar with the drugs used to treat it. For that reason, we have
reprinted a Table summarizing key information about these drugs
published as part of a comprehensive review on the topic that
appeared in the February 24, 2020, issue of The Medical Letter on
Drugs and Therapeutics.
—Edward Livingston, MD, Deputy Editor, JAMA

Table. Some Drugs for Depression

Drug Some available formulations Initial adult dosagea Usual adult dosagea Costb
Selective serotonin reuptake inhibitors (SSRIs)
Citalopram – generic 10, 20, 40 mg tabs; 2 mg/mL soln 20 mg once/d 20-40 mg once/dc $2.40
Celexa (Allergan) 10, 20, 40 mg tabs 272.10
Escitalopram – generic 5, 10, 20 mg tabs; 1 mg/mL soln 10 mg once/d 10-20 mg once/dd 4.80
Lexapro (Allergan) 5, 10, 20 mg tabs 362.20
Fluoxetine – generic 10, 20, 40 mg caps; 10, 20, 60 mg tabs; 20 mg once/d 20-60 mg once/d 2.70e
4 mg/mL soln
Prozac (Lilly) 10, 20, 40 mg caps 489.00
Delayed-release – generic 90 mg DR caps 90 mg once/wk 90 mg once/wk 130.70
Paroxetine HCI – generic 10, 20, 30, 40 mg tabs 20 mg once/d 20-60 mg once/d 4.10
Paxil (Apotex) 10, 20, 30, 40 mg tabs; 2 mg/mL susp 202.50
Extended-release – generic 12.5, 25, 37.5 mg ER tabs 12.5 mg once/d 25-75 mg once/d 83.90
Paxil CR 208.60
Paroxetine mesylate – Pexeva (Sebela) 20, 30, 40 mg tabs 20 mg once/d 20-50 mg once/d 391.40
Sertraline – generic 25, 50, 100 mg tabs; 50 mg once/d 50-200 mg once/d 11.40
Zoloft (Pfizer) 20 mg/mL soln 350.90
Serotonin–norepinephrine reuptake inhibitors (SNRIs)
Desvenlafaxine succinate – generic 25, 50, 100 mg ER tabs 50 mg once/d 50 mg once/d 161.00
Pristiq (Pfizer) 412.80
Desvenlafaxine – generic 50, 100 mg ER tabs 50 mg once/d 50 mg once/d 248.40
Duloxetine – generic 20, 30, 60 mg DR caps 40-60 mg once/d 60-120 mg once/d or 43.70
or divided bid divided bid
Cymbalta (Lilly) 256.80
Drizalma Sprinkle (Sun) 30, 40, 60 mg DR caps 175.50
Venlafaxine – generic 25, 37.5, 50, 75, 100 mg tabs 37.5 mg once/d 75-375 mg/d divided bid 10.60
or tid
Extended-release – generic 37.5, 75, 150 mg ER caps; 37.5, 75, 150, 37.5-75 mg once/d 75-375 mg once/d 9.00f
225 mg ER tabs
Effexor XR (Pfizer) 37.5, 75, 150 mg ER caps 465.00
Levomilnacipran – Fetzima (Allergan) 20, 40, 80, 120 mg ER caps 20 mg once/d × 2 d, 40-120 mg once/d 412.40
then 40 mg once/d
Tricyclic antidepressants (TCAs)g
Amitriptyline – generic 10, 25, 50, 75, 100, 150 mg tabs 25-50 mg once/d or divided 100-300 mg once/d or 28.50
divided
Amoxapine – generic 50, 100, 150 mg tabs 25-50 mg once/d, bid, or tid 200-300 mg/d divided bid 88.10
or tid
Desipramine – generic 10, 25, 50, 75, 100, 150 mg tabs 25-50 mg once/d or divided 100-300 mg once/d or 82.90
divided
Norpramin (Validus) 10, 25 mg tabs 222.00
Imipramine – generic 10, 25, 50 mg tabs 25-50 mg once/d or divided 100-300 mg once/d or 24.80
divided
Imipramine pamoate – generic 75, 100, 125, 150 mg caps 75 mg once/d 150 mg once/d 354.00
Nortriptyline – generic 10, 25, 50, 75 mg caps; 2 mg/mL soln 25 mg once/d 50-200 mg once/d or 29.40
divided
Pamelor (Mallinckrodt) 10, 25, 50, 75 mg caps 1226.00

(continued)

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 From The Medical Letter on Drugs and Therapeutics Clinical Review & Education

Table. Some Drugs for Depression (continued)

Drug Some available formulations Initial adult dosagea Usual adult dosagea Costb
Monoamine oxidase inhibitors (MAOIs)
Isocarboxazid – Marplan (Validus) 10 mg tabs 10 mg bid 30-60 mg/d divided 446.10
Phenelzine – generic 15 mg tabs 15 mg tid 45-90 mg/d divided 58.50
Nardil (Pfizer) 144.60
Selegiline – Emsam (Mylan) 6, 9, 12 mg/24 h patches 6 mg/24 h 6, 9, 12 mg/24 h 1756.80
Tranylcypromine – generic 10 mg tabs 10 mg once/d 20-30 mg bid 324.00
Parnate (Concordia) 883.50
Others
Brexanolone – Zulresso (Sage 100 mg/20 mL single-use vials See footnotei See footnotei 37 250.00j
Therapeutics)h
Bupropion HCI – generic 75, 100 mg tabs 100 mg bid 100 mg tid 63.00
Extended-release (12 h) – generic 100, 150, 200 mg ER tabs 150 mg once/d 150 mg bid 19.00
Wellbutrin SR (GSK) 445.30
Extended-release (24 h) – generic 150, 300 mg ER tabs 150 mg once/d 300-450 mg once/d 78.30
Wellbutrin XL (Valeant) 1940.20
Forfivo XL (Almatica) 450 mg ER tabs See footnotek 450 mg once/d 446.90
Bupropion hydrobromide – Aplenzin (Valeant) 174, 348, 522 mg ER tabs 174 mg once/d 348 mg once/d 1962.40
Esketamine – Spravato (Janssen) 56, 84 mg kits 56 mg intranasally 56 or 84 mg intranasally 1237.80
× 1 dosel q1 or 2 wk
Mirtazapine – generic 7.5, 15, 30, 45 mg tabs 15 mg once/d at bedtime 15-45 mg once/d 6.00
Remeron (Organon) 15, 30 mg tabs 160.20
Orally disintegrating – generic 15, 30, 45 mg ODT 53.00
Remeron SolTab 127.50
Nefazodonem – generic 50, 100, 150, 200, 250 mg tabs 50 mg once/d 150-300 mg/d divided bid 78.50
Olanzapine/fluoxetine – generic 3/25, 6/25, 6/50, 12/25, 12/50 mg caps 6/25 mg once/d 6/25-12/50 mg once/d 321.80
Symbyax (Lilly) 3/25, 6/25, 6/50, 12/50 mg caps 402.30n
Trazodone – generic 50, 100, 150, 300 mg tabs 75 mg bid 150-600 mg/d divided bid 36.10
Vilazodone – Viibryd (Allergan) 10, 20, 40 mg tabs 10 mg once/d 20-40 mg once/d 285.90
Vortioxetine – Trintellix (Takeda/Lundbeck) 5, 10, 20 mg tabs 10 mg once/d 10-20 mg once/d 383.70
g
Abbreviations: DR, delayed-release; ER, extended-release; ODT, orally Narrowtherapeuticindex:serumconcentrationsshouldbemonitoredatsteadystate.
disintegrating tablets; soln, solution; susp, suspension. Therapeutic serum concentrations are: amitriptyline 100-250 ng/mL; desipramine
a
Dosage adjustments may be needed for renal or hepatic impairment or for drug ⱖ125 ng/mL; imipramine ⱖ200 ng/mL; nortriptyline 50-150 ng/mL.
h
interactions. Lower initial dosages may be considered for elderly patients. FDA-approved only for treatment of postpartum depression.
b i
Approximate WAC for 30 days’ treatment at the lowest usual adult dosage. Administered as a continuous IV infusion over 60 hours at varying rates.
WAC = wholesaler acquisition cost or manufacturer’s published price to At 0-4 and 56-60 hours: 30 μg/kg/h; 4-24 and 52-56 hours: 60 μg/kg/h;
wholesalers; WAC represents a published catalogue or list price and may not 24-52 hours: 90 μg/kg/h. If the 90 μg/kg/h infusion is not tolerated, the dose
represent an actual transactional price. Source: AnalySource® Monthly. can be reduced to 60 μg/kg/h.
February 5, 2020. Reprinted with permission by First Databank, Inc. All rights j
Cost of 5 vials.
reserved. ©2020. www.fdbhealth.com/drug-pricing-policy. k
Initiate treatment with another bupropion formulation.
c
Maximumdailydoseis40mg(20mginpatientswhoare>60yearsold,havehepatic l
Administer 56 mg twice/week for weeks 1-4 and 56 mg or 84 mg once/week
impairment, are CYP2C19 poor metabolizers, or are taking a CYP2C19 inhibitor).
for weeks 5-8.
d
Maximum daily dose is 20 mg. The recommended dose for most elderly m
Brand-name nefazodone (Serzone) was withdrawn from the market due to
patients and those with hepatic impairment is 10 mg/d.
hepatotoxicity.
e
Cost of capsules. Cost for tablets is $20.10. n
Wholesale cost according to the manufacturer.
f
Cost of capsules. Cost for tablets is $115.30.

ARTICLE INFORMATION
Once a month, The Medical Letter provides a previously
published article to JAMA to be republished.
Previous Publication: This article was published in
The Medical Letter on Drugs and Therapeutics.
February 24, 2020;62(1592):25-32. It is reprinted
here with permission from ©The Medical Letter Inc.
About The Medical Letter: The Medical Letter is a
nonprofit organization that publishes biweekly new
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and Editor in Chief
REFERENCES
1. Whooley MA. Diagnosis and treatment of
depression in adults with comorbid medical
conditions. JAMA. 2012;307(17):1848-1857. doi:10.
1001/jama.2012.3466
2. Zimmerman M. Using the 9-item Patient Health
Questionnaire to screen for and monitor
depression. JAMA. 2019;322(21):2125-2126. doi:10.
1001/jama.2019.15883

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