1.1. Adults
The FDA requires that all antidepressant drugs display a black box warning describing the potential for increased suicidal thinking and behavior compared to placebo when prescribed to young adults (18 to 24 years of age) with MDD and other psychiatric disorders. In short-term clinical trials, the suicide risk was increased in young adults managed with antidepressants compared to those receiving placebo in the first few months of treatment. Suicide risk was not shown to increase in adults over 24 years of age, and patients 65 years of age and older manifested a decreased suicide risk. Patients of all ages prescribed antidepressant drugs should be closely monitored for changes in behavior, clinical worsening, or suicidality1-2.
Citalopram is FDA approved for treatment of Major Depressive Disorder (MDD), Escitalopram is FDA approved for Generalized Anxiety Disorder (GAD) and MDD. Fluoxetine is FDA approved for Bipolar I Disorder (BD), Bulimia Nervosa (BN), Obsessive Compulsive Disorder (OCD), Panic Disorder (PD), Premenstrual Dysphoric Disorder (PMDD), and MDD. Fluvoxamine is FDA approved for OCD. Paroxetine is FDA approved for Seasonal Affective Disorder (SAD), Post Traumatic Stress Disorder (PTSD), Vasomotor Symptoms associated with Menopause (VMS), GAD, MDD, OCD, PDD, and PMDD. Sertraline is FDA approved for MDD, OCD, PD, SAD, PTSD, and PMDD. Olanzapine/Fluoxetine is FDA approved for Treatment Resistant Depression (TRD) and BD1-17.
Maximum recommended daily doses for SSRI antidepressant drugs in adults, including the elderly population, are summarized in Tables 1 and 2 for both monotherapy and SSRI combination therapy, respectively. However, in all patients, the lowest effective antidepressant dose should be utilized to minimize unwanted adverse effects. Patient profiles with SSRI antidepressant dosages exceeding these recommendations will be reviewed.
Drug Name | Available Dosage Strengths | Treatment Indication | Maximum Recommended Dosage |
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citalopram (Celexa®, generics) | 10 mg, 20 mg, 40 mg tablets; 30 mg capsule; 10 mg/ 5 mL oral solution | MDD |
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escitalopram (Lexapro®, generics) | 5 mg, 10 mg, 20 mg tablets; 5 mg/5 mL oral solution | GAD, MDD |
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fluoxetine (Prozac®, generics) | 10 mg, 20 mg, 40 mg capsules; 10 mg, 20 mg, 40 mg, 60 mg tablets; 20 mg/5 mL solution | MDD, OCD |
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BN, PD |
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BD, TRD |
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fluoxetine (Prozac® Weekly, generics) | 90 mg delayed-release capsules | MDD |
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fluoxetine (Prozac Pulvules®) | 10 mg, 20 mg, 40 mg pulvules | MDD, OCD |
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BN, PD |
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BD, TRD |
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fluoxetine (generics) | 10 mg, 20 mg capsules | PMDD |
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fluvoxamine (generics) | IR: 25 mg, 50 mg, 100 mg tablets ER: 100 mg, 150 mg 24-hour ER capsules |
OCD |
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paroxetine mesylate (Pexeva®) | 10 mg, 20 mg, 30 mg tablets | GAD, MDD |
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OCD, PD |
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paroxetine HCl (Paxil®, generics) | 10 mg, 20 mg, 30 mg, 40 mg tablets, 10 mg/ 5 mL suspension | OCD, PD |
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MDD, PTSD |
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SAD |
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GAD |
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paroxetine HCl (Paxil CR®, generics) | 12.5 mg, 25 mg, 37.5 mg 24-hour ER tablets | MDD |
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PD |
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SAD |
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PMDD |
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Paroxetine mesylate (Brisdelle®, generics) | 7.5 mg capsule | VMS |
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sertraline (Zoloft®, generics) | 25 mg, 50 mg, 100 mg tablets; 20 mg/mL oral concentrate | MDD, OCD, PD, SAD, PTSD |
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PMDD |
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Legend:
- BD = bipolar I disorder;
- BN = bulimia nervosa
- CR = controlled-release
- ER = extended-release
- GAD = generalized anxiety disorder
- IR = immediate-release
- MDD = major depressive disorder
- OCD = obsessive-compulsive disorder
- PD = panic disorder
- PMDD = premenstrual dysphoric disorder
- PTSD = posttraumatic stress disorder
- SAD = social anxiety disorder
- VMS = vasomotor symptoms associated with menopause
- * Fluvoxamine IR doses greater than 100 mg daily should be administered in divided doses, if dose is unequal larger doses should be given at bedtime
- ++ Data do not confirm that paroxetine doses greater than 20 mg/day are more effective
- + Lower doses may be required in elderly patients
- ^ In combination with olanzapine
Treatment Indication | Drug Name | Available Dosage Strengths | Maximum Recommended Dosage |
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BD, TRD | olanzapine/ fluoxetine (Symbyax®, generics) | 3 mg/ 25 mg, 6 mg/ 25 mg, 12 mg/25 mg, 6 mg/ 50 mg, 12 mg/ 50 mg capsules |
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Legend:
- BD = bipolar I disorder
- TRD = treatment-resistant depression