Depression Screening Tool Kit

Anti-Depressant Doses and Side Effects

For Adults
For Children/Adolescents

Anti-Depressant Doses and Side Effect Comparison

	Adult Dosing		Adverse Effect Potential
	Starting Dose (mg)	Therapeutic dose range (mg)	Sedation	Anti-cholinergic	Insomnia/Agitation	Orthostatic Hypotension	Sexual dysfunction	Wt. gain	GI	QT c
SSRIs
Citalopram	20	20-40	0	0	1+	1+	3+	1+	1+	2+
Escitalopram	10	10-20	0	0	1+	1+	3+	1+	1+	1+
Fluoxetine	20¹	20-80	0	0	2+	1+	3+	1+	1+	1+
Paroxetine	20¹	20-50	1+	1+	1+	2+	4+	2+	1+	1+
Sertraline	50	25-200	0	0	2+	1+	3+	1+	2+	1+
SNRIs
Duloxetine	20 BID²	40-60	0	0	2+	0	3+	0		0
Venlafaxine ER	75	75-225	0	0	2+	0	3+	0	2+	1+
MISC.
Bupropion XL³	150¹	300-450	0	0	2+	0	0	0	2+	1+
Mirtazapine	15 QHS	15-45	4+	1+	0	0	1+	4+		1+
¹use lower doses in elderly and preferably dose in the morning; ²dose BID initially, then can change to daily; ³contraindicated if significant anxiety, seizure disorder, active alcohol use or history of an eating disorder

Anti-Depressant Dosing and Side Effects for Ages 12+

	Dosing for Ages 12+				SAFETY²	EFFICACY
SSRI Medication	Starting Dose	Titration¹ Increments (mg)	Therapeutic Dose (mg)	Maximum Dose (mg)	Side Effects³ evaluate each for drug interactions	RCT Evidence **FDA approved
First-line Agents
Fluoxetine	10 mg PO daily	10-20	20	60	Headaches, GI upset, insomnia, agitation, anxiety Note: long half-life minimizes risk of discontinuation syndrome with poor adherence	Y**
Second-line Agents
Escitalopram	5 mg PO daily	5	10-20	20	Headaches, GI upset, insomnia	Y**
Third-line Agents
Citalopram	10 mg PO daily	10	20	40	Headaches, GI upset, insomnia	Y
Sertraline	25 mg PO daily	12.5-25	100	200	Headaches, GI upset	Y
¹Optmizing the SSRI dose: Full medication effects will not be observed until 4-6 weeks after initiation; however, some response should be observed at 2-3 weeks of a therapeutic dose. If no response at 2-3 weeks, the dose should be increased. Optimal dose is when significant improvement occurs in presenting symptoms, PHQ-9 score is <5 and side effects of medication are either absent or tolerable ²Side effect evaluation: If mild, wait 7 days to determine if transient. If they persist but are tolerable, continue on the dose. If side effects are moderate, reduce the dose or change the dosing schedule or drug. If side effects are severe, discontinue or change the medication as soon as possible. ³ Treatment Emergent Activation Syndrome (TEAS) (common and tends to occur in early treatment phase; presents as agitation, dysphoria, or akathisia, with no striking mood changes) may occur with any SSRI, consult BHI team if concerns arise; often responds to dose reduction or slowed titration. Other potential common side effects may include: dry mouth, sweating, irritability, disinhibition, agitation, jitteriness, appetite changes, or rash More serious, less common side effects include: serotonin syndrome, akathisia, hypomania, or discontinuation syndrome

Anti-Depressant Treatment Algorithm Combination Therapies

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Ankle Brachial Index

ABI Value	Interpretation	Recommendation
Greater than 1.4	Calcification/vessel hardening	Refer to vascular specialist
1.0 - 1.4	Normal	None
0.9 - 1.0	Acceptable	None
0.8 - 0.9	Some arterial disease	Treat risk factor
0.5 - 0.8	Moderate arterial disease	Refer to vascular specialist
Less than 0.5	Severe arterial disease	Refer to vascular specialist