Major Depressive Disorder Treatments

MAJOR DEPRESSIVE DISORDER TREATMENTS
Generic	Brand	Strength	Form	Dose
ATYPICAL ANTIPSYCHOTICS¹
brexpiprazole	Rexulti¹	0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg	tabs	Adults: Initially 0.5mg or 1mg once daily; titrate weekly up to target dose of 2mg/day; max 3mg/day. Moderate to severe hepatic impairment (Child-Pugh ≥7), or renal impairment (CrCl <60mL/min): max 2mg/day. CYP2D6 poor metabolizers: give ½ of usual dose; and if taking with moderate/strong CYP3A4 inhibitors: give ¼ of usual dose. Concomitant strong CYP3A4 inhibitors: give ½ of usual dose. Concomitant moderate/strong CYP2D6 with moderate/strong CYP3A4 inhibitors: give ¼ of usual dose. Concomitant strong CYP3A4 inducers: double usual dose over 1–2wks. Children: Not established.
cariprazine	Vraylar¹	1.5mg, 3mg, 4.5mg, 6mg	caps	Adults: Initially 1.5mg once daily; may increase to 3mg on Day 15 based on response and tolerability; max 3mg/day. Initiating a strong CYP3A4 inhibitor while on Vraylar: reduce Vraylar dose by ½. Initiating Vraylar while already on a strong CYP3A4 inhibitor: give 1.5mg on Days 1 and 3 (no dose on Day 2), then 1.5mg daily from Day 4 onward; increase to max 3mg/day. Children: Not established.
quetiapine	Seroquel XR¹	50mg, 150mg, 200mg, 300mg, 400mg	ext-rel tabs	Adults: 50mg/day on days 1 and 2, then 150mg/day on day 3, then titrate to effective dose, usual range: 150–300mg/day. Elderly or hepatic impairment: initially 50mg/day; may increase at increments of 50mg/day. Children: Not established.
MONOAMINE OXIDASE INHIBITORS (MAOIs)
isocarboxazid	Marplan²	10mg+	tabs	Adults: Initially 10mg twice daily. May increase by 10mg every 2–4 days up to 40mg daily. If tolerated, may increase by 20mg/week to max 60mg/day divided into 2–4 doses. Children: <16yrs: not recommended.
phenelzine	Nardil²	15mg	tabs	Adults: Initially 15mg three times daily. Increase if needed to max 90mg daily. Reduce dose as condition improves. Children: <16yrs: not recommended.
selegiline	Emsam	6mg/24hr, 9mg/24hr, 12mg/24hr	transdermal system	Adults: Initially one 6mg/24hrs patch once daily. May titrate at intervals of ≥2wks in increments of 3mg/24hrs; max 12mg/24hrs. Elderly (≥65yrs): 6mg/24hrs once daily. Children: ≤17yrs: not recommended.
tranylcypromine	Parnate²	10mg	tabs	Adults: Initially 30mg daily in divided doses. If inadequate response, may increase in 10mg/day increments every 1–3wks; usual max 60mg/day. Children: Not established.
N-METHYL-D-ASPARTATE (NMDA) ANTAGONISTS
dextromethorphan/ bupropion	Auvelity	45mg/105mg	ext-rel tabs	Adults: Initially 1 tab once daily in the AM for 3 days, then increase to 1 tab twice daily (at least 8hrs apart). Max 2 doses daily. Moderate renal impairment (eGFR 30–59mL/min/1.73m²), concomitant strong CYP2D6 inhibitors, poor CYP2D6 metabolizers: reduce to 1 tab once daily in the AM. Children: Not established.
esketamine	Spravato¹	28mg	nasal spray	Adults: MDD³: 84mg twice weekly for 4wks; may reduce to 56mg twice weekly based on tolerability. TRD⁴: Induction phase (Weeks 1–4): Day 1 starting dose: 56mg; subsequent doses: 56mg or 84mg twice weekly. Evaluate for continued treatment after the induction phase. Maintenance phase (Weeks 5–8): 56mg or 84mg once weekly; (Weeks 9 and after): 56mg or 84mg every 2wks or once weekly (frequency should be individualized). Children: Not established.
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
citalopram	Celexa	10mg, 20mg+, 40mg+	tabs	Adults: Initially 20mg once daily; after ≥1wk may increase to max 40mg/day. Elderly (>60yrs), hepatic impairment, CYP2C19 poor metabolizers, concomitant cimetidine or other CYP2C19 inhibitors: max 20mg/day. Children: Not established
citalopram	Celexa	2mg/mL	oral soln
escitalopram	Lexapro	5mg, 10mg+, 20mg+	tabs	Adults: Initially 10mg once daily; may increase to max 20mg once daily at an interval of no less than 1 week. Elderly or hepatic impairment: 10mg once daily. Children: <12yrs: not established. 12–17yrs: initially 10mg once daily; may increase to 20mg once daily after 3wks.
escitalopram	Lexapro	1mg/mL	oral soln
fluoxetine	—	60mg+	tabs	Adults: Initially 20mg daily in AM; increase if needed after several weeks. May give doses >20mg/day in 2 divided doses (AM and noon); max 80mg/day. Children: <8yrs: not established. 8–18yrs: initially 10mg or 20mg/day; if started on 10mg/day, increase after 1 week to 20mg/day. Lower weight children: start at 10mg/day; may increase after several weeks to 20mg/day.
	Prozac	10mg, 20mg, 40mg	caps
	Prozac	20mg/5mL	oral soln
paroxetine	Paxil	10mg+, 20mg+, 30mg+, 40mg+	tabs	Adults: Initially 20mg/day, usually in the AM. Adjust by 10mg/day at 1wk intervals; max 50mg/day. Elderly, debilitated, severe hepatic or renal impairment: initially 10mg/day; max 40mg/day. Children: Not established.
	Paxil	10mg/5mL	oral susp
	Paxil CR	12.5mg, 25mg, 37.5mg	ext-rel tabs	Adults: Initially 25mg/day, usually in the AM. Adjust by 12.5mg/day at 1wk intervals; max 62.5mg/day. Elderly, debilitated, severe hepatic or renal impairment: initially 12.5mg/day; max 50mg/day. Children: Not established.
sertraline	Zoloft	20mg+, 50mg+, 100mg+	tabs	Adults: Initially 50mg once daily in AM or PM; may increase by 25–50mg/day at 1wk intervals; max 200mg/day. Children: Not established.
sertraline	Zoloft	20mg/mL	oral soln
SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)
desvenlafaxine	Pristiq	25mg, 50mg, 100mg	ext-rel tabs	Adults: 50mg once daily. Moderate renal impairment (CrCl 30–50mL/min): max 50mg/day. Severe renal impairment (CrCl <30mL/min), ESRD: max 25mg daily or 50mg every other day. Do not give supplemental dose after dialysis. Moderate to severe hepatic impairment: max 100mg/day. Withdraw gradually. Children: Not established.
duloxetine	Cymbalta	20mg, 30mg, 60mg	del-rel caps	Adults: Initially 40mg/day (given as 20mg twice daily) to 60mg/day (given either once daily or as 30mg twice daily); may start at 30mg once daily for 1 week, if needed; usual target 60mg once daily (doses up to 120mg/day have been given). Maintenance: 60mg once daily. Children: Not established.
levomilnacipran	Fetzima	20mg, 40mg, 80mg, 120mg	ext-rel caps	Adults: Initially 20mg once daily for 2 days, and then increase to 40mg once daily; may increase dose in 40mg increments at intervals of ≥2 days; max 120mg once daily. Renal impairment: moderate (CrCl 30–59mL/min): max 80mg once daily; severe (CrCl 15–29mL/min): max 40mg once daily. ESRD: not recommended. Concomitant strong CYP3A4 inhibitors: max 80mg once daily. Children: Not established.
venlafaxine	—	25mg+, 37.5mg+, 50mg+, 75mg+, 100mg+	tabs	Adults: Initially 75mg/day in 2–3 divided doses; may increase at 4-day intervals in 75mg/day increments to 150mg/day; max 375mg/day, in 3 divided doses. Hepatic impairment: reduce by at least 50%. Renal impairment (mild or moderate): reduce by 25–50%; (severe or undergoing hemodialysis): reduce dose by at least 50%. Withdraw gradually (over 2wks). Children: Not established.
venlafaxine	Effexor XR	37.5mg, 75mg, 150mg	ext-rel caps	Adults: Initially 75mg once daily; may start at 37.5mg once daily for 4–7 days before increasing to 75mg/day; may increase by increments of up to 75mg/day at intervals of at least 4 days; usual max 225mg/day. Hepatic impairment: reduce by at least 50%. Renal impairment (mild or moderate): reduce by 25–50%; (severe or undergoing hemodialysis): reduce dose by at least 50%. Withdraw gradually (reduce by 75mg/day at 1wk intervals). Transferring from immediate-release: give total daily dose on once-daily basis. Children: Not established.
SEROTONIN MODULATORS
vilazodone	Viibryd	10mg, 20mg, 40mg	tabs	Adults: Initially 10mg once daily for 7 days, then 20mg once daily for 7 days, then increase to 40mg once daily. Concomitant strong CYP3A4 inhibitors: max 20mg once daily. Concomitant strong CYP3A4 inducers for >14 days: consider increasing dose up to 2-fold over 1–2wks; max 80mg daily. Readjust to original level when CYP3A4 inhibitors or inducers (in 14 days) are discontinued. Children: Not established.
vortioxetine	Trintellix	5mg, 10mg, 20mg	tabs	Adults: Initially 10mg once daily; then, increase to 20mg/day, as tolerated. May consider 5mg/day if unable to tolerate. Discontinuing treatment: may reduce to 10mg/day for one week before full discontinuation of 15mg/day or 20mg/day. CYP2D6 poor metabolizers: max 10mg/day. Concomitant strong CYP2D6 inhibitors: reduce vortioxetine dose by ½; increase to original dose when inhibitor is discontinued. Concomitant strong CYP inducers for >14 days: consider increasing vortioxetine dose up to max 3x original dose; reduce to original dose within 14 days when inducer is discontinued. Children: Not established.
TRICYCLIC ANTIDEPRESSANTS
amitriptyline	—	10mg, 25mg, 50mg, 75mg, 100mg, 150mg	tabs	Adults: Initially 75mg daily in divided doses or 50–100mg daily at bedtime; max 150mg daily. Elderly and adolescents: reduce dose. Children: Not recommended.
amoxapine	—	25mg+, 50mg+, 100mg+, 150mg+	tabs	Adults: Initially 50mg 2–3 times daily; may increase to 100mg 2–3 times daily by the end of the first week. May increase above 300mg/day if dose has been ineffective for a period of at least 2wks. Maintenance: when effective dosage established, may give as single dose at bedtime (max 300mg). Elderly: initially 25mg 2–3 times daily; may increase by the end of the first week to 50mg 2–3 times daily. May increase carefully up to 300mg/day if necessary. Children: Not established.
doxepin	—	10mg, 25mg, 50mg, 75mg, 100mg, 150mg	caps	Adults: Mild: 25–50mg/day. Mild to moderate: initially 75mg/day; range 75–150mg/day. Severe: max 300mg/day. May give as single (up to 150mg) or divided doses; 150mg caps for maintenance only. Soln: dilute with 4oz juice, water, or milk. Children: Not recommended.
doxepin	—	10mg/mL	oral soln
desipramine	—	10mg, 25mg, 50mg, 75mg, 100mg, 150mg	tabs	Adults: 100–200mg daily in single or divided doses; max 300mg/day. Hospitalize initially if dose is 300mg/day; monitor ECG. Elderly and adolescents: 25–100mg/day in single or divided doses; max 150mg/day. Children: Not recommended.
imipramine HCl	—	10mg, 25mg, 50mg	tabs	Adults: Outpatients: initially 75mg/day, may increase to 150mg/day; max 200mg/day. Maintenance: 50–150mg/day. Inpatients: initially 100mg/day, may increase to 200mg/day as needed; max 300mg/day. Adolescents or elderly: initially 30–40mg/day; max 100mg/day. Children: Not established.
imipramine pamoate	—	75mg, 100mg, 125mg, 150mg	caps	Adults: Give once a day at bedtime or in divided doses. Outpatients: initially 75mg/day; max 200mg/day. Inpatients: initially 100–150mg/day, max 300mg/day. Adolescents or elderly: start with imipramine HCl tabs 25–50mg/day; usual max 100mg/day. For maintenance doses >75mg, may switch to imipramine pamoate caps. Children: Not established.
nortriptyline	—	10mg/5mL	oral soln	Adults: Initially 25mg 3–4 times daily; max 150mg/day. Elderly and adolescents: 30–50mg/day in single or divided doses. Children: Not recommended.
nortriptyline	Pamelor	10mg, 25mg, 50mg, 75mg	caps
protriptyline	—	5mg, 10mg	tabs	Adults: Initially 15–40mg daily in 3–4 divided doses. Increase AM dose if needed; max 60mg/day. Elderly, adolescents: initially 5mg 3 times daily. Children: Not established.
trimipramine	—	25mg, 50mg, 100mg	caps	Adults: Give in divided doses; may give maintenance dose once at bedtime. Outpatients: initially 75mg/day, may increase to 150mg/day, max 200mg/day; maintenance: 50–150mg/day. Hospitalized: initially 100mg/day, may increase gradually to 200mg/day; if no improvement in 2–3wks, may increase to max 250–300mg/day. Adolescents and elderly: initially 50mg/day, may increase gradually to 100mg/day. Children: Not established.
OTHERS
bupropion	—	75mg, 100mg	tabs	Adults: Initially 100mg twice daily for at least 3 days; if tolerated, increase to 100mg 3 times daily at least 6hrs apart; max increase 100mg/day per 3-day period. May increase after several weeks to max 450mg/day in 3 divided doses; max single dose: 150mg (give 400mg/day as 100mg 4 times daily at least 4hrs apart). Moderate to severe hepatic impairment: max 75mg/day. Renal or mild hepatic impairment: consider reduced dose and/or dose frequency. Children: Not established.
	Aplenzin	174mg, 348mg, 522mg	ext-rel tabs	Adults: Initially 174mg once daily; after 4 days, may increase to target dose of 348mg once daily. Increase dose gradually to reduce seizure risk; max 522mg/day. Severe hepatic impairment: max 174mg every other day. Renal or mild-moderate hepatic dysfunction: reduce dose and/or frequency. Children: Not established.
	Forfivo XL⁵	450mg	ext-rel tabs	Adults: 450mg once daily. May be used in patients receiving 300mg/day of another bupropion forms for at least 2wks and requiring a 450mg/day dose. Taper dose using another bupropion form prior to stopping Forfivo XL. Switching from other bupropion forms at 450mg/day: give equivalent dose of Forfivo XL once daily. Children: Not established.
	Wellbutrin SR	100mg, 150mg, 200mg	sust-rel tabs	Adults: Initially 150mg once daily in the AM for at least 3 days; if tolerated, increase to 150mg twice daily at least 8hrs apart. May increase after several weeks to max 200mg twice daily at least 8hrs apart. Moderate to severe hepatic impairment: max 100mg/day or 150mg every other day. Renal or mild hepatic impairment: consider reduced dose and/or dose frequency. Children: Not established.
	Wellbutrin XL	150mg, 300mg	ext-rel tabs	Adults: Initially 150mg once daily in the AM for at least 4 days; if tolerated, increase to 300mg once daily in the AM at least 24hrs apart. May increase after several weeks to max 450mg/day. Moderate to severe hepatic impairment: max 150mg every other day. Renal or mild hepatic impairment: consider reduced dose and/or dose frequency. Children: Not established.
mirtazapine	Remeron	15mg+, 30mg+	tabs	Adults: Initially 15mg once daily at bedtime; increase at intervals of at least 1–2wks; max 45mg/day. SolTab: Dissolve on tongue and swallow with or without water. Children: Not established.
mirtazapine	Remeron SolTab	15mg, 30mg, 45mg	ODT
nefazodone	—	50mg, 100mg+, 150mg+, 200mg, 250mg	tabs	Adults: Initially 200mg/day in 2 divided doses; increase in increments of 100–200mg/day in 2 divided doses at 1-week intervals; range 300–600mg/day. Elderly or debilitated: 100mg/day in 2 divided doses. Children: Not established.
olanzapine/ fluoxetine	Symbyax⁴	3mg/25mg, 6mg/25mg	caps	Adults: Initially 6mg/25mg; range: 6–18mg/25–50mg. Risk of hypotension, hepatic impairment, slow metabolizers, or sensitive to olanzapine: initially 3mg/25mg to 6mg/25mg; titrate slowly and adjust as needed. Children: Not established.
trazodone	—	50mg, 100mg, 150mg+, 300mg+	tabs	Adults: Initially 150mg/day in divided doses with food. May increase by 50mg/day at 3–4 day intervals; max 400mg/day (outpatients) or 600mg/day (inpatients) in divided doses; give most of dose at bedtime. Children: Not established.
NOTES
Key: + = scored; del-rel = delayed-release; ext-rel = extended-release; MDD = major depressive disorder; ODT = orally-disintegrating tablet; sust-rel = sustained-release; TRD = treatment-resistant depression ¹ As adjunct to antidepressants. ² Not as first-line therapy. Use in patients refractory to other antidepressants. ³ MDD with acute suicidal ideation or behavior. ⁴ For TRD, defined as MDD in patients who failed to respond to 2 or more separate trials of different antidepressants of adequate dose and duration in the current episode. ⁵ Not for treatment initiation. Use other forms of bupropion for initial dose titration. Not an inclusive list of medications and/or official indications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling. Created 11/2023

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