List of Antidepressants
SSRIs
1.	Celexa (citalopram) 
Description CITALOPRAM (Celexa ™) is a medicine for depression and other related problems. Celexa is a potent serotonin reuptake inhibitor. 
Pharmacology: You may have to take citalopram for up to 4 weeks or longer before you begin to feel better. 
Indications and Usage: Citalopram hydrobromide is indicated for the symptomatic relief of depressive illness.  The relapse rate was significantly lower in citalopram-treated patients than in placebo-treated patients in two placebo-controlled studies, that were conducted over a 24-week period in patients who responded to 6 or 8 weeks of acute treatment with citalopram. Nevertheless, the physician who elects to use citalopram for extended periods should periodically reevaluate the long-term usefulness of the drug for the individual patient. 
Contraindications: Citalopram hydrobromide (Celexa) is contraindicated in patients with known hypersensitivity to citalopram hydrobromide or the excipients of the drug product. 
Monoamine Oxidase Inhibitors (MAOI)
In patients, receiving selective serotonin reuptake inhibitors (SSRIs) in combination with a monoamine oxidase inhibitor (MAOI), there have been reports of serious, sometimes fatal, reactions including hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes, including extreme agitation progressing to delirium and coma. These reactions have also been reported in patients who have recently discontinued SSRI treatment and have been started on a MAOI. Some cases presented with features resembling serotonin syndrome. Therefore, it is recommended that citalopram should not be used in combination with a MAOI or within 14 days of discontinuing treatment with a MAOI. Similarly, at least 14 days should elapse after discontinuing citalopram treatment before starting a MAOI.
Warnings : Visit your prescriber or health care professional for regular checks on your progress. Continue to take your tablets even if you do not immediately feel better. It can take about 4 weeks before you feel the full effect of citalopram. If you have suicidal thoughts, call your prescriber or health care professional at once. If you are going to have surgery, tell your prescriber or health care professional that you are taking citalopram. 
If you have been taking citalopram regularly for some time, do not suddenly stop taking it. You must gradually reduce the dose, or your symptoms may get worse. Ask your prescriber or health care professional for advice.
You may get drowsy or dizzy. Do not drive, use machinery, or do anything that needs mental alertness until you know how citalopram affects you. Do not stand or sit up quickly, especially if you are an older patient. This reduces the risk of dizzy or fainting spells. Alcohol may interfere with the effect of citalopram. Avoid alcoholic drinks. Do not treat yourself for coughs, colds, or allergies without asking your prescriber or health care professional for advice. Some ingredients can increase possible side effects.
Precautions: Suicide: The possibility of a suicide attempt is inherent in depression and may persist until remission occurs. Therefore, high risk patients should be closely supervised throughout therapy with Citalopram hydrobromide and consideration should be given to the possible need for hospitalization. In order to minimize the opportunity for overdosage, prescription for citalopram should be written for the smallest quantity of drug consistent with good patient management. 
Activation of Mania/Hypomania: In placebo-controlled trials with citalopram, some of which included patients with bipolar disorder, mania/hypomania was reported in 0.1% of 1027 patents treated with citalopram versus none of the 426 patients treated with placebo. Activation of mania/hypomania has also been reported in a small proportion of patients with major affective disorders treated with other marketed antidepressants. If a patient enters a manic phase, citalopram should be discontinued.
Seizures: Citalopram has not been systematically evaluated in patients with a seizure disorder. These patients were excluded from clinical studies during the premarketing testing of citalopram. In clinical trials, seizures occurred in 0.25% of patients treated with citalopram and in 0.23% patients treated with placebo. Like other antidepressants, citalopram should be used with caution in patients with a history of seizure disorder. 
Serotonin Syndrome: Rarely, the occurrence of serotonin syndrome has been reported in patients receiving SSRIs. A combination of symptoms, possibly including agitation, confusion, tremor, myoclonus and hyperthermia, may indicate the development of this condition.
5-HT1 Agonists: There have been rare postmarketing reports describing patients with weakness, hyperreflexia and incoordination, following the concomitant use of a SSRI and the antimigraine drug sumatriptan, a 5-HT1 agonist. Such interaction should be considered if citalopram is to be used in combination with a 5-HT1 agonist. 
Hyponatremia: Hyponatremia and SIADH (syndrome of inappropriate antidiuretic hormone secretion) have been reported with citalopram use as a rare adverse event.
Hepatic Impairment: The use of citalopram in hepatically impaired patients should be approached with caution and a lower maximum dosage is recommended.
Use in Patients with Cardiac Disease: Citalopram has not been systematically evaluated in patients with a recent history of myocardial infarction or unstable heart disease. Patients with these diagnoses were generally excluded from clinical trials during the drugs premarketing assessment. However, the electrocardiograms of patients, who received citalopram in clinical trials, indicate that citalopram was not associated with the development of clinically significant ECG abnormalities.
In clinical trials, citalopram caused small but statistically significant decreases in heart rate. Consequently, caution should be observed when citalopram is initiated in patients with pre-existing slow heart rate.
Use in Diabetic Patients: Citalopram has not been systematically evaluated in diabetic patients since diabetes constituted an exclusion criterion. Although 13 patients did receive insulin during the studies, this number is too small to determine whether citalopram affects the response to insulin. Rare events of hypoglycemia were reported. Citalopram should be used with caution in diabetic patients on insulin or other antidiabetic drugs.
Interference with Cognitive and Motor Performance: In studies in normal volunteers, citalopram in doses of 40 mg/day did not impair cognitive function or psychomotor performance. However, psychotropic medications may impair judgement, thinking or motor skills. Consequently, patients should be cautioned against driving a car or operating hazardous machinery until they are reasonably certain that citalopram does not affect them adversely. 
Pregnancy and Nursing Mothers: The safety of citalopram during pregnancy and lactation has not been established. Therefore, citalopram should not be used during pregnancy, unless, in the opinion of the physician, the expected benefits to the patient markedly outweigh the possible hazards to the fetus. Citalopram is excreted in human milk. Citalopram should not be administered to nursing mothers unless, in the opinion of the treating physician, the expected benefits to the patient markedly outweigh the possible hazards to the child.
Pediatric Use: Safety and effectiveness in children below the age of 18 years have not been established. 
Geriatric Use: Geriatric Use in premarketing clinical trials, 800 elderly patients (>=65 years of age) have been treated with citalopram. Of these patients 298 were >=75 years old. In a pharmacokinetic study (n=11, age 73 to 90 years), clearance was substantially decreased and half-life prolonged. In a 6-week placebo-controlled study, approximately equal numbers of patients received citalopram at 20 or 30 mg per day, as the final dose. In about 5% of patients, the final dose was 10 mg per day. Consequently, elderly patients should be administered lower doses and a lower maximum dose. 
Drug Interactions: Monoamine Oxidase Inhibitors (MAOI) - Do not take citalopram with any of the following medications: •medicines called MAO inhibitors-phenelzine (Nardil®), tranylcypromine (Parnate®), isocarboxazid (Marplan®), selegiline (Eldepryl®)
Also: alprazolam, amphetamine, buspirone; certain diet drugs (dexfenfluramine, fenfluramine, sibutramine); certain medicines for blood pressure or heart problems (bisoprolol, diltiazem, encainide, flecainide, metoprolol, mexiletine, mibefridil, nicardipine, penbutolol, pindolol, propafenone, propranolol, verapamil); certain steroids (dexamethasone, methylprednisolone, prednisone); cimetidine, cyproheptadine, dextromethorphan, dextroamphetamine, diazepam, fluvastatin, grapefruit juice, kava kava, linezolid, lithium, medicines that treat HIV infection or AIDS, migraine headache medicines (naratriptan, rizatriptan, sumatriptan, zolmitriptan), certain seizure medicines (carbamazepine, ethosuximide, phenobarbital, phenytoin, primidone, topiramate), medicines for mental problems and psychotic disturbances (clozapine, haloperidol, phenothiazines, risperidone, thiothixene), modafinil, nefazodone, omeprazole, prescription pain relievers (codeine, hydrocodone, meperidine, morphine, oxycodone), procarbazine, quinine, some medicines for infections (clarithromycin, clotrimazole, erythromycin, fluconazole, furazolidone, isoniazid, INH, itraconazole, ketoconazole, metronidazole, norfloxacin, rifabutin, rifampin, troleandomycin), St. John's Wort, trazodone, tricyclic antidepressant medications, like amitriptyline or imipramine, troglitazone, tryptophan, valerian, venlafaxine, zafirlukast.
Switching from Celexa to MAOI or vice versa: At least 14 days should elapse between discontinuation of a MAOI and initiation of therapy with citalopram. Similarly, at least 14 days should be allowed after stopping citalopram before starting a MAOI.
Alcohol: Although citalopram did not potentiate the cognitive and psychomotor effects of alcohol in volunteers, the concomitant use of alcohol and citalopram should be avoided.
BEFORE USING THIS MEDICINE: INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. Also tell your prescriber or health care professional if you are a frequent user of grapefruit juice, drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.
Adverse Reactions:Side effects that you should report to your prescriber or health care professional as soon as possible: 
Rare or uncommon: confusion, dizziness or lightheadedness, skin rash, itching (hives), fast talking and excited feelings or actions that are out of control, suicidal thoughts, vomiting. 
Other Side Effects: The following additional adverse reactions have been reported: agitation or restlessness, blurred vision, diarrhea, difficulty sleeping, drowsiness, dry mouth, fever, frequent urination, headache, indigestion, nausea, increased or decreased appetite, increased sweating, sexual difficulties (decreased sexual ability or desire), taste alterations, tremor (shaking), weight changes.
Overdose Signs and Symptoms: Citalopram hydrobromide has a wide margin of safety in overdose. Cases of overdoses involved the ingestion of citalopram either alone or in combination with other drugs and/or alcohol. In clinical trials, with overdoses of citalopram ranging from 180 mg to 2000 mg, all patients recovered. Symptoms most often accompanying citalopram overdose included dizziness, sweating, nausea, vomiting, tremor, and somnolence. In more rare cases, observed symptoms included confusion, loss of consciousness, convulsions, coma, sinus tachycardia, cyanosis, hyperventilation and rhabdomyolysis. 
Treatment: Establish and maintain an airway to ensure adequate ventilation and oxygenation. Gastric lavage and use of activated charcoal should be considered. Cardiac and vital sign monitoring are recommended, along with general symptomatic and supportive measures. There are no specific antidotes for citalopram. 
Dosage: HOW TO USE THIS MEDICINE: DO NOT EXCEED THE RECOMMENDED DOSE or take this medicine for longer than prescribed.
•	Follow the directions for using this medicine provided by your doctor. 
•	Take this medicine with water. 
•	Citalopram hydrobromide (Celexa) should be administered once daily, in the morning or evening, with or without food. Follow the directions on the prescription label. 
•	Store this medicine at room temperature, away from heat and light. 
•	If you miss a dose of this medicine, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. Follow your prescriber or health care professional's advice on missed doses. Do not take double or extra doses. 
•	Do not stop taking this medicine without first checking with your doctor. 
Adults: Citalopram (Celexa) should be administered as a single oral dose of 20 mg/day. In patients who do not respond adequately, an increase of dosage to 40 mg/day should be considered. Certain patients may require 60 mg/day. However, in a dose response study, the 60 mg/day dose did not demonstrate an advantage regarding effectiveness over the 40 mg/day dose. Dose increases should usually occur in increments of 20 mg, at intervals of no less than one week. 
Elderly: A single oral dose of 20 mg/day is the recommended dose for most elderly patients. Some patients may respond to a 10 mg/day dose.
Hepatic Impairment: Patients with reduced hepatic function should receive dosages of no more than 30 mg/day.
Additional Information: Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children. 
IF USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, obtain refills before your supply runs out. 
How Supplied: 20 mg tablets: Each oval, white, scored, film-coated tablet, marked "C" and "N", symmetrically around the score contains 20 mg citalopram (as citalopram hydrobromide). Blister packages of 30 tablets and bottles of 100 tablets. 40 mg tablets: Each oval, white, scored, film-coated tablet, marked "C" and "R", symmetrically around the score contains 40 mg citalopram (as citalopram hydrobromide). Blister packages of 30 tablets. 
2.	Lexapro (escitalopram oxalate) 
3.	Luvox (fluvoxamine) 
4.	Paxil (paroxetine) 
Description: Paxil is a selective serotonin reuptake inhibitor (SSRI) used to treat obsessive-compulsive disorder (OCD), depression and panic disorder. 
Pharmacology: Paxil (paroxetine hydrochloride) is an orally administered antidepressant with a chemical structure unrelated to other selective serotonin reuptake inhibitors or to tricyclic, tetracyclic or other available antidepressant agents. The antidepressant action of paroxetine and its efficacy in the treatment of obsessive compulsive disorder (OCD) and panic disorder (PD) is presumed to be linked to potentiation of serotonergic activity in the central nervous system resulting from inhibition of neuronal reuptake of serotonin. Steady-state plasma concentrations of paroxetine are generally achieved in 7 to 10 days, although it may take substantially longer in an occasional patient.
AT LEAST 1 TO 2 WEEKS, and sometimes up to 4 weeks, may pass before this medicine reaches its full effect.
Indications and Usage-Paxil (paroxetine hydrochloride) is indicated for the treatment of depression, obsessive-compulsive disorder (OCD), and panic disorder-with or without agoraphobia. 
Contraindications-Paroxetine (Paxil) is contraindicated in patients who are known to be hypersensitive to the drug. 
Monoamine Oxidase Inhibitors: Paroxetine should not be used in combination with MAO inhibitors or within 2 weeks of terminating treatment with MAO inhibitors. Treatment with paroxetine should then be initiated cautiously and dosage increased gradually until optimal response is reached. MAO inhibitors should not be introduced within 2 weeks of cessation of therapy with paroxetine. 
Warnings -Potential for Interaction with Monoamine Oxidase Inhibitors : In patients receiving another serotonin reuptake inhibitor drug in combination with a monoamine oxidase inhibitor (MAOI), there have been reports of serious, sometimes fatal, reactions including hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes that include extreme agitation progressing to delirium and coma. These reactions have also been reported in patients who have recently discontinued that drug and have been started on a MAOI. Some cases presented with features resembling neuroleptic malignant syndrome. While there are no human data showing such an interaction with Paxil, limited animal data on the effects of combined use of paroxetine and MAOIs suggest that these drugs may act synergistically to elevate blood pressure and evoke behavioral excitation. Therefore it is recommended that Paxil (paroxetine hydrochloride) not be used in combination with a MAOI, or within 14 days of discontinuing treatment with a MAOI. At least 2 weeks should be allowed after stopping Paxil before starting a MAOI.
Precautions-Activation of Mania/Hypomania: Paxil may trigger hypomania or mania episodes in unipolar and bipolar individuals. As with all antidepressants, Paxil should be used cautiously in patients with a history of mania. 
Suicide: The possibility of a suicide attempt is inherent in depression and may persist until remission occurs. Therefore, high risk patients should be closely supervised throughout therapy and consideration should be given to the possible need for hospitalization. In order to minimize the opportunity for overdosage, prescriptions for paroxetine should be written for the smallest quantity of drug consistent with good patient management. 
Seizures: Caution is recommended when the drug is administered to patients with a history of seizures. The drug should be discontinued in any patient who develops seizures. 
Hyponatremia: Several cases of hyponatremia have been reported. The hyponatremia appeared to be reversible when Paxil was discontinued. The majority of these occurrences have been in elderly individuals, some in patients taking diuretics or who were otherwise volume depleted. 
Abnormal Bleeding: There have been several reports of abnormal bleeding (mostly ecchymosis and purpura) associated with paroxetine treatment, including a report of impaired platelet aggregation. While a causal relationship to paroxetine is unclear, impaired platelet aggregation may result from platelet serotonin depletion and contribute to such occurrences. 
Use in Patients with Concomitant Illness: Clinical experience with Paxil in patients with certain concomitant systemic illness is limited. Caution is advisable in using Paxil in patients with diseases or conditions that could affect metabolism or hemodynamic responses. 
Cardiac Conditions: Paxil has not been evaluated or used to any appreciable extent in patients with a recent history of myocardial infarction or unstable heart disease. Clinical studies indicated Paxil (paroxetine hydrochloride) does not cause any clinically important changes in heart rate or blood pressure or any significant ECG abnormalities.
Usage in Children: Do not give to children under 18 years old.
Pregnancy & Nursing: The effect of paroxetine on labor and delivery in humans is unknown. Therefore, Paxil should be used in women who are or might become pregnant only if the clinical condition clearly justifies potential risk to the fetus.
Like many other drugs, paroxetine is secreted in human milk, and caution should be exercised when Paxil (paroxetine hydrochloride) is administered to a nursing woman. 
Interference with Cognitive or Motor Performance: Any psychoactive drug may impair judgment, thinking or motor skills. Although in controlled studies Paxil has not been shown to impair psychomotor performance, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that Paxil therapy does not affect their ability to engage in such activities. 
Drug Interactions-Tryptophan: As with other serotonin reuptake inhibitors, an interaction between paroxetine and tryptophan may occur when they are co-administered. Adverse experiences, consisting primarily of headache, nausea, sweating and dizziness, have been reported when tryptophan was administered to patients taking Paxil (paroxetine hydrochloride). Consequently, concomitant use of Paxil with tryptophan is not recommended.
Monoamine Oxidase Inhibitors: Paroxetine should not be used in combination with MAO inhibitors or within 2 weeks of terminating treatment with MAO inhibitors. Treatment with paroxetine should then be initiated cautiously and dosage increased gradually until optimal response is reached. MAO inhibitors should not be introduced within 2 weeks of cessation of therapy with paroxetine. 
Warfarin: Preliminary data suggest that there may be a pharmacodynamic interaction (that causes an increased bleeding diathesis in the face of unaltered prothrombin time) between paroxetine and warfarin. Since there is little clinical experience, the concomitant administration of Paxil and warfarin should be undertaken with caution. 
Sumafriptan: There have been rare postmarketing reports describing patients with weakness, hyperreflexia, and incoordination following the use of a selective serotonin reuptake inhibitor (SSRI) and sumatriptan. If concomitant treatment with sumatriptan and an SSRI (e.g., fluoxetine, fluvoxamine, paroxetine, sertraline) is clinically warranted, appropriate observation of the patient is advised.
Drugs Affecting Hepatic Metabolism: The metabolism and pharmacokinetics of paroxetine may be affected by the induction or inhibition of drug-metabolizing enzymes. Cimetidine, Phenobarbital, Phenytoin.
Drugs Metabolized by Cytochrome P450IID6: Many drugs, including most antidepressants (paroxetine, other SSRls and many tricyclics), are metabolized by the cytochrome P450 isozyme P45011D6. Concomitant use of Paxil with other drugs metabolized by cytochrome P45011D6 has not been formally studied but may require lower doses than usually prescribed for either Paxil or the other drug. 
Therefore, co-administration of Paxil with other drugs that are metabolized by this isozyme, including certain antidepressants (e.g., nortriptyline, amitriptyline, imipramine, desipramine and fluoxetine), phenothiazines (e.g., thioridazine) and Type iC antiarrhythmics (e.g., propafenone, flecainide and encainide), or that inhibit this enzyme (e.g., quinidine), should be approached with caution.
Tricyclic Antidepressants (TCA): Caution is indicated in the co-administration of tricyclic antidepressants (TCAs) with Paxil, because paroxetine may inhibit TCA metabolism. Plasma TCA concentrations may need to be monitored, and the dose of TCA may need to be reduced, if a TCA is co-administered with Paxil (see above—Drugs Metabolized by Cytochrome P45011D6).
Lithium, Digoxin, Diazapam: Since there is little clinical experience, the concurrent administration of paroxetine and the above drugs should be undertaken with caution. 
BEFORE USING THIS MEDICINE: INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. This includes cyproheptadine, clozapine, dexfenfluramine, fenfluramine, astemizole, terfenadine, lithium, selegiline, tramadol, and medicines used to treat depression. Inform your doctor of any other medical conditions, allergies, pregnancy, or breast-feeding. 
Adverse Reactions-When Used for Depression: The most commonly observed adverse events associated with the use of paroxetine (Paxil) were: asthenia, sweating, nausea, decreased appetite, somnolence, dizziness, insomnia, tremor, nervousness, ejaculatory disturbance and other male genital disorders. 
When Used for OCD: The most commonly observed adverse events associated with the use of paroxetine were: nausea, dry mouth, decreased appetite, constipation. dryness, somnolence, tremor, sweating, impotence and abnormal ejaculation.
When Used for Panic Disorder: The most commonly observed adverse events associated with the use of paroxetine were: asthenia, sweating, decreased appetite, libido decreased, tremor, abnormal ejaculation, female genital disorders and impotence. 
Other rarer side effects that should be reported immediately to your doctor: Diarrhea; difficulty in speaking; drowsiness; dryness of mouth; fever; inability to move eyes; increased sweating; increased thirst; lack of energy; loss of or decrease in body movements; mood or behavior changes; overactive reflexes; racing heartbeat; restlessness; shivering or shaking; sudden or unusual body or face movements; talking, feeling, and acting with excitement and activity you cannot control.
Other possible side effects: Constipation; decreased sexual ability; dizziness; headache; nausea; problems in urinating; tremor; trouble in sleeping; unusual tiredness or weakness; vomiting; anxiety or nervousness; blurred vision; change in your sense of taste; decreased or increased appetite; decreased sexual desire; fast or irregular heartbeat; tingling, burning, or prickly sensations; weight loss or gain 
DO NOT DRINK ALCOHOL while you are taking this medicine. 
Dependence & Withdrawl: Paxil (paroxetine hydrochloride) is not a controlled substance. Paxil has not been systematically studied in animals or humans for its potential for abuse, tolerance or physical dependence. While the clinical trials did not reveal any tendency for any drug-seeking behavior, these observations were not systematic and it is not possible to predict on the basis of this limited experience the extent to which a CNS-active drug will be misused, diverted and/or abused once marketed. Consequently, patients should be evaluated carefully for history of drug abuse, and such patients should be observed closely for signs of Paxil misuse or abuse (e.g., development of tolerance, incrementations of dose drug-seeking behavior). 
Overdose -Signs and Symptoms -Overdose with Paxil (up to 2000 mg) alone and in combination with other drugs has been reported. Signs and symptoms of overdose with Paxil include nausea, vomiting, sedation, dizziness, sweating, and facial flush. There are no reports of coma or convulsions following overdosage with Paxil alone. A fatal outcome has been reported rarely when Paxil was taken in combination with other agents, or when taken alone. Other symptoms of overdose may include fast heartbeat and dilated pupils. 
Treatment-If you or someone you know may have used more than the recommended dose of this medicine, contact your local poison control center or emergency room immediately.
Maintain adequate airway, empty stomach contents, and treat symptomatically.
Treatment should be supportive and in response to clinical signs and symptoms. Respiration, pulse and blood pressure should be monitored and supported by general measures when necessary. Immediate gastric lavage should be performed followed by administration of activated charcoal. 
Dosage-Do not exceed the recommended dosage or take this medicine for longer than prescribed. Continue to take this medicine even if you feel better. Do not miss any doses.
At least 1-2 weeks, and sometimes up to 4 weeks, may pass before this medicine reaches its full effect. 
•	Follow the directions for using this medicine provided by your doctor. 
•	Store this medicine at room temperature, away from heat and light. 
•	This medicine may be taken on an empty stomach or with food. 
•	If you miss a dose of this medicine, and you are taking it in the morning, take it during the afternoon if you remember. If you do not remember until the next morning, skip the missed dose and go back to your regular dosing schedule. If you miss a dose and you are taking a daily dose at bedtime and do not remember until the next day, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. 
Additional Information: Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children. 
IF USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, obtain refills before your supply runs out. 
For Depression:-Adults: Usual Initial Dosage: Paxil (paroxetine hydrochloride) should be administered as a single daily dose, usually in the morning. The recommended initial dose is 20 mg/day. Patients were dosed in a range of 20 to 50 mg/day in the clinical trials demonstrating the antidepressant effectiveness of Paxil. As with all antidepressants, the full antidepressant effect may be delayed. Some patients not responding to a 20 mg dose may benefit from dose increases, in 10 mg/day increments, up to a maximum of 50 mg/day. Dose changes should occur at intervals of at least 1 week. 
Maintenance Therapy: There is no body of evidence available to answer the question of how long the patient treated with Paxil should remain on it. It is generally agreed that acute episodes of depression require several months or longer of sustained pharmacologic therapy. Whether the dose of an antidepressant needed to induce remission is identical to the dose needed to maintain and/or sustain euthyrnia is unknown. Systematic evaluation of the efficacy of Paxil (paroxetine hydrochloride) has shown that efficacy is maintained for periods of up to 1 year with doses that averaged about 30 mg. 
For Obsessive-Compulsive Disorder (OCD): 
Adults: Paxil (paroxetine hydrochloride) should be administered as a single daily dose, usually in the morning. The recommended dose of Paxil in the treatment of OCD is 40 mg daily. Patients should be started on 20 mg/day and the dose can be increased in 10 mg/day increments. Dose changes should occur at intervals of at least 1 week. Patients were dosed in a range of 20 to 60 mg/day in the clinical trials demonstrating the effectiveness of Paxil in the treatment of OCD.
Maintenance Therapy: It is reasonable to consider continuation for a responding patient. Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment. 
For Panic Disorder:
Adults: Paxil should be administered as a single daily dose, usually in the morning. The target dose of Paxil in the treatment of panic disorder is 40 mg/day. Patients should be started on 10 mg/day. Dose changes should occur in 10 mg/week increments and at intervals of at least 1 week. Patients were dosed in a range of 10 to 60 mg/day in the clinical trials demonstrating the effectiveness of Paxil. The maximum dosage should not exceed 60 mg/day. 
Maintenance Therapy: Panic disorder is a chronic condition, and it is reasonable to consider continuation for a responding patient. Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.
Elderly or Debilitated, and Patients with Severe Renal or Hepatic Impairment: The recommended initial dose is 10 mg/ day for elderly patients, debilitated patients, and/o( patients with, severe renal or hepatic impairment. Increases may be made if indicated. Dosage should not exceed 40 mg/day. Switching Patients to or from a Monoamine Oxidese Inhbitor: At least 14 days should elapse between discontinuation of a MACI and initiation of Paxil therapy. Similarly, at least 14 days should be allowed after stopping Paxil before starting a MAOI. 
Children under 18 years of age: The use of paroxetine in children under 18 years of age is not recommended as safety and efficacy have not been established in this population. 
How Supplied-Tablets:-Each film-coated tablet contains paroxetine hydrochloride equivalent to paroxetine as follows: 10 mg, 20 mg, 30 mg, 40 mg.-Suspension for Oral Administration:-Each 5 mL of orange-colored, orange-flavored liquid contains paroxetine hydrochloride equivalent to paroxetine, 10mg. 
5.	Prozac (fluoxetine) 
Fluoxetine
Brand Name: Prozac, Serafem-	
Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, obsessive-compulsive disorder (OCD), or bulimia. Fluoxetine is also used to treat premenstrual dysphoric disorder (PMDD), symptoms of which occur in the week or two before a woman's menstrual period and commonly include irritability, mood swings, and tension as well as the physical symptoms of bloating and breast tenderness. Prozac is also approved to treat panic disorder with or without agoraphobia.
Pharmacology-The antidepressant, antiobsessive-compulsive, and antibulimic actions of fluoxetine (Prozac) are presumed to be linked to its inhibition of CNS neuronal uptake of serotonin. Studies at clinically relevant doses in man have demonstrated that fluoxetine blocks the uptake of serotonin into human platelets. Studies in animals also suggest that fluoxetine is a much more potent uptake inhibitor of serotonin than of norepinephrine.
In humans, following a single oral 40 mg dose, peak plasma concentrations of fluoxetine from 15 to 55 ng/ mL are observed after 6 to 8 hours.
Sometimes fluoxetine must be taken for up to 4 weeks or longer before you begin to feel better. Your doctor should check your progress at regular visits during this time. 
Indications and Usage-Prozac is indicated for the treatment of depression.-Prozac is indicated for the treatment of obsessions and compulsions in patients with obsessive-compulsive disorder (OCD).
Bulimia Nervosa -- Prozac is indicated for the treatment of binge-eating and vomiting behaviors in patients with moderate to severe bulimia nervosa. 
Contraindications-Prozac is contraindicated in patients known to be hypersensitive to it.
Monoamine Oxidase Inhibitors: There have been reports of serious, sometimes fatal, reactions (including hyperthermia, rigidity, myoclonus, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes that include extreme agitation progressing to delirium and coma) in patients receiving fluoxetine in combination with a monoamine oxidase inhibitor (MAOI), and in patients who have recently discontinued fluoxetine and are then started on an MAOI. Some cases presented with features resembling neuroleptic malignant syndrome. Therefore, Prozac should not be used in combination with an MAOI, or within a minimum of 14 days of discontinuing therapy with an MAOI.
In addition, at least 5 weeks, perhaps longer, should be allowed after stopping Prozac before starting an MAOI. 
Warnings -Rash and Possibly Allergic Events: In US fluoxetine clinical trials, 7% of 10,782 patients developed various types of rashes and/ or urticaria. Among the cases of rash and/ or urticaria reported in premarketing clinical trials, almost a third were withdrawn from treatment because of the rash and/ or systemic signs or symptoms associated with the rash. Clinical findings reported in association with rash include fever, leukocytosis, arthralgias, edema, carpal tunnel syndrome, respiratory distress, symphadenopathy, proteinuria, and mild transaminase elevation. Most patients improved promptly with discontinuation of fluoxetine and/ or adjunctive treatment with antihistamines or steroids, and all patients experiencing these events were reported to recover completely.
In premarketing clinical trials, 2 patients are known to have developed a serious cutaneous systemic illness. In neither patient was there an unequivocal diagnosis, but 1 was considered to have a leukocytoclastic vasculitis, and the other, a severe desquamating syndrome that was considered variously to be a vasculitis or erythema multiforme. Other patients have had systemic syndromes suggestive of serum sickness.
Since the introduction of Prozac, systemic events, possibly related to vasculitis, have developed in patients with rash. Although these events are rare, they may be serious, involving the lung, kidney, or liver. Death has been reported to occur in association with these systemic events.
Anaphylactoid events, including bronchospasm, angioedema, and urticaria alone and in combination, have been reported. 
Pulmonary events, including inflammatory processes of varying histopathology and/ or fibrosis, have been reported rarely. These events have occurred with dyspnea as the only preceding symptom. 
Whether these systemic events and rash have a common underlying cause or are due to different etiologies or pathogenic processes is not known. Furthermore, a specific underlying immunologic basis for these events has not been identified. 
Upon the appearance of rash or of other possibly allergic phenomena for which an alternative etiology cannot be identified, Prozac should be discontinued.
Precautions-Anxiety and Insomnia: In clinical trials for depression, 12% to 16% of patients treated with Prozac reported anxiety, nervousness, or insomnia.
For obsessive-compulsive disorder, insomnia was reported in 28% of patients treated with Prozac. Anxiety was reported in 14% of patients treated with Prozac.
For bulimia nervosa, insomnia was reported in 33% of patients treated with Prozac. Anxiety and nervousness were reported respectively in 15% and 11% of patients treated with Prozac.
Altered Appetite and Weight: Significant weight loss, especially in underweight depressed or bulimic patients may be an undesirable result of treatment with Prozac.
Fluoxetine should be given with caution to patients suffering from anorexia nervosa and only if the expected benefits (e.g., co-morbid depression) markedly outweigh the potential weight reducing effect of the drug. 
Activation of Mania/ Hypomania: In US clinical trials for depression, mania/ hypomania was reported in 0.1% of patients treated with Prozac.
Seizures: Fluoxetine should be used with caution in patients with a history of convulsive disorders.
Suicide: The possibility of a suicide attempt is inherent in depression and may persist until significant remission occurs. Close supervision of high risk patients should accompany initial drug therapy. Prescriptions for Prozac should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose.
Because of well- established comorbidity between both OCD and depression and bulimia and depression, the same precautions observed when treating patients with depression should be observed when treating patients with OCD or bulimia. 
Use in Patients With Concomitant Illness: Clinical experience with Prozac in patients with concomitant systemic illness is limited. Caution is advisable in using Prozac in patients with diseases or conditions that could affect metabolism or hemodynamic responses.
Cardiovascular: Fluoxetine has not been evaluated or used to any appreciable extent in patients with a recent history of myocardial infarction or unstable heart disease.
Liver: A lower or less frequent dose should be used in patients with cirrhosis.
Diabetics: In patients with diabetes, Prozac may alter glycemic control. Hypoglycemia has occurred during therapy with Prozac, and hyperglycemia has developed following discontinuation of the drug. As is true with many other types of medication when taken concurrently by patients with diabetes, insulin and/ or oral hypoglycemic dosage may need to be adjusted when therapy with Prozac is instituted or discontinued.
Usage in Children: The efficacy of Prozac for the treatment of major depressive disorder was demonstrated in two 8- to 9-week placebo-controlled clinical trials with 315 pediatric outpatients ages 8 to=18. 
The efficacy of Prozac for the treatment of OCD was demonstrated in one 13-week placebo-controlled clinical trial with 103 pediatric outpatients ages 7 to <18.
The safety and effectiveness in pediatric patients <8 years of age in major depressive disorder and <7 years of age in OCD have not been established.
Fluoxetine pharmacokinetics were evaluated in 21 pediatric patients (ages 6 to=18) with major depressive disorder or OCD. 
The acute adverse event profiles observed in the 3 studies (N=418 randomized; 228 fluoxetine-treated, 190 placebo-treated) were generally similar to that observed in adult studies with fluoxetine. The longer-term adverse event profile observed in the 19-week major depressive disorder study (N=219 randomized; 109 fluoxetine-treated, 110 placebo-treated) was also similar to that observed in adult trials with fluoxetine.
Manic reaction, including mania and hypomania, was reported in 6 (1 mania, 5 hypomania) out of 228 (2.6%) fluoxetine-treated patients and in 0 out of 190 (0%) placebo-treated patients. Mania/hypomania led to the discontinuation of 4 (1.8%) fluoxetine-treated patients from the acute phases of the 3 studies combined. Consequently, regular monitoring for the occurrence of mania/hypomania is recommended.
As with other SSRIs, decreased weight gain has been observed in association with the use of fluoxetine in children and adolescent patients. After 19 weeks of treatment in a clinical trial, pediatric subjects treated with fluoxetine gained an average of 1.1 cm less in height (p=0.004) 15 and 1.1 kg less in weight (p=0.008) than subjects treated with placebo. In addition, fluoxetine treatment was associated with a decrease in alkaline phosphatase levels. The safety of fluoxetine treatment for pediatric patients has not been systematically assessed for chronic treatment longer than several months in duration. In particular, there are no studies that directly evaluate the longer-term effects of fluoxetine on the growth, development, and maturation of children and adolescent patients. Therefore, height and weight should be monitored periodically in pediatric patients receiving fluoxetine.
Pregnancy & Nursing: The effect of Prozac on labor and delivery in humans is unknown. However, because fluoxetine crosses the placenta and because of the possibility that fluoxetine may have adverse effects on the newborn, fluoxetine should be used during labor and delivery only if the potential benefit justifies the potential risk to the fetus. 
Because Prozac is excreted in human milk, nursing while on Prozac is not recommended.
Interference with Cognitive or Motor Performance: Any psychoactive drug may impair judgment, thinking, or motor skills, and patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug treatment does not affect them adversely.
Drug Interactions-As with all drugs, the potential for interaction by a variety of mechanisms (eg, pharmacodynamic, pharmacokinetic drug inhibition or enhancement, etc) is a possibility.-Do not use fluoxetine and MAO inhibitors at the same time.-BEFORE USING THIS MEDICINE: INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. This includes cyproheptadine, lithium, dextromethorphan, selegiline, and medicines used to treat high blood pressure, seizures, and depression. Using these medicines in combination with Prozac can produce an adverse reaction.
Antipsychotics: Some clinical data suggests a possible pharmacodynamic and/ or pharmacokinetic interaction between serotonin specific reuptake inhibitors (SSRIs) and antipsychotics. Elevation of blood levels of haloperidol and clozapine has been observed in patients receiving concomitant fluoxetine. A single case report has suggested possible additive effects of pimozide and fluoxetine leading to bradycardia.
Anticonvulsants: Patients on stable doses of phenytoin and carbamazepine have developed elevated plasma anticonvulsant concentrations and clinical anticonvulsant toxicity following initiation of concomitant fluoxetine treatment.
Five patients receiving fluoxetine in combination with tryptophan experienced adverse reactions, including agitation, restlessness and gastrointestinal distress. 
Inform your doctor of any other medical conditions, including kidney or liver disease, allergies, pregnancy, or breast-feeding. 
Adverse Reactions-Side Effects That Should Be Reported To Your Doctor: Characterized as less common- Chills or fever; joint or muscle pain; skin rash, hives, or itching; trouble in breathing. -Characterized as rare- Burning or tingling in fingers, hands, or arms; convulsions (seizures); signs of low blood sugar, including anxiety or nervousness, cold sweats, confusion, cool pale skin, difficulty in concentration, drowsiness, excessive hunger, fast heartbeat, headache, shakiness or unsteady walk, or unusual tiredness or weakness; swelling of feet or lower legs; swollen glands; talking, feeling, and acting with excitement and activity you cannot control.
Side Effects That Usually Do Not Require Immediate Medical Attention 
In clinical trials, the most commonly observed adverse events associated with the use of fluoxetine include nervousness, trouble sleeping, headache, drowsiness, fatigue, nausea, vomiting, diarrhea, loss of appetite, dry mouth, sweating, dizziness, lightheadedness, muscle spasms, or changes in sexual function. If they continue or are bothersome, check with your doctor. 
Other less common side effects- Abnormal dreams; change in taste; changes in vision; chest pain; constipation; cough; decrease in concentration; fast or irregular heartbeat; feeling of warmth or heat; flushing or redness of skin, especially on face and neck; frequent urination; increased appetite; menstrual pain; stomach cramps, gas, or pain; stuffy nose; tiredness or weakness; tremor.
If you notice other effects not listed above, contact your doctor, nurse, or pharmacist. 
Drug Abuse and Dependence
Prozac is not a controlled substance. Since introduction, reports of death attributed to overdose of fluoxetine alone have been rare. 
Overdose -Signs and Symptoms -Symptoms of overdose of Prozac may include nausea, vomiting, seizures, and restlessness. 
Treatment - If you or someone you know may have used more than the recommended dose of this medicine, contact your local poison control center or emergency room immediately.
Establish and maintain an airway; ensure adequate oxygenation and ventilation. Activated charcoal, which may be used with sorbitol, may be as or more effective than emesis or lavage, and should be considered in treating overdose. Cardiac and vital signs monitoring is recommended, along with general symptomatic and supportive measures. There are no specific antidotes for Prozac. 
In managing overdosage, consider the possibility of multiple drug involvement.
Dosage-As with other antidepressants, the full antidepressant effect of Prozac may be delayed until 4 weeks of treatment or longer. -At least 14 days should elapse between discontinuation of an MAOI and initiation of therapy with Prozac. In addition, at least 5 weeks, perhaps longer, should be allowed after stopping Prozac before starting an MAOI.
•	Follow the directions for using this medicine provided by your doctor. 
•	Store this medicine at room temperature, away from heat and light. 
•	Continue to take this medicine even if you feel better. Do not stop without checking with your doctor. 
•	If you miss a dose of this medicine, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. 
•	This medicine may be taken with food if it upsets your stomach. 
Additional Information: Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children. 
Depression:
Adults: The recommended initial dosage is 20 mg administered once daily in the morning. A gradual dose increase should be considered only after a trial period of several weeks if the expected clinical improvement does not occur. 
Bulimia Nervosa:
Adults: The recommended dosage is 60 mg/day, although studies show that lower doses may also be efficacious. Electrolyte levels should be assessed prior to initiation of treatment. 
Obsessive-Compulsive Disorder:
Adults: A dose range of 20 mg/day to 60 mg/day is recommended. 
For all indications, the total Prozac dosage should not exceed a maximum of 80 mg/day.
Maintenance/ Continuation/ Extended Treatment: It is generally agreed that acute episodes of depression require several months or longer of sustained pharmacologic therapy. 
While there are no systematic studies that answer the question of how long to continue Prozac, bulimia and ocd are chronic conditions and it is reasonable to consider continuation for a responding patient. 
Elderly & Debilitated Patients: Lower doses are recommended in these patients since they may be more sensitive to the drug.
Pediatric (children and adolescents): In the short-term (8 to 9 week) controlled clinical trials of fluoxetine supporting its effectiveness in the treatment of major depressive disorder, patients were administered fluoxetine doses of 10 to 20 mg/day. Treatment should be initiated with a dose of 10 or 20 mg/day. After 1 week at 10 mg/day, the dose should be increased to 20 mg/day.
However, due to higher plasma levels in lower weight children, the starting and target dose in this group may be 10 mg/day. A dose increase to 20 mg/day may be considered after several weeks if insufficient clinical improvement is observed.
In the controlled clinical trial of fluoxetine supporting its effectiveness in the treatment of OCD, patients were administered fluoxetine doses in the range of 10 to 60 mg/day.
In adolescents and higher weight children, treatment should be initiated with a dose of 10 mg/day. After 2 weeks, the dose should be increased to 20 mg/day. Additional dose increases may be considered after several more weeks if insufficient clinical improvement is observed. A dose range of 20 to 60 mg/day is recommended.
In lower weight children, treatment should be initiated with dose of 10 mg/day. Additional dose increases may be considered after several more weeks if insufficient clinical improvement is observed. A dose range of 20 to 30 mg/day is recommended. Experience with daily doses greater than 20 mg is very minimal, and there is no experience with doses greater than 60 mg.
IF USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, obtain refills before your supply runs out. How Supplied Liquid: Oral Solution is available in: 20 mg per 5 mL with mint flavor. It contains Fluoxetine HCl equivalent to fluoxetine 20 mg. Capsules: 10 mg: The 10 mg Pulvule is opaque green and green, imprinted with DISTA 3104 on the cap and Prozac 10 mg on the body, contains: Fluoxetine HCl equivalent to fluoxetine 10 mg.  20 mg: The 20 mg Pulvule is an opaque green cap and off- white body, imprinted with DISTA 3105 on the cap and Prozac 20 mg on the body, contains: Fluoxetine HCl equivalent to fluoxetine 20 mg.
6.	Zoloft (sertraline) 
MOAIs
1.	Nardil (phenelzine) 
2.	Parnate (tranylcypromine) 
Tricyclics
1.	Adapin (doxepin) 
2.	Anafranil (clomipramine) 
3.	Elavil (amitriptyline) 
4.	Endep (amitriptyline) 
5.	Ludiomil (maprotiline) 
6.	Norpramin (desipramine) 
7.	Pamelor (nortryptyline) 
8.	Pertofrane (desipramine) 
9.	Sinequan (doxepin) 
10.	Surmontil (trimipramine) 
11.	Tofranil (imipramine) 
12.	Vivactil (protriptyline) 
Others
1.	Buspar (buspirone) 
2.	Cymbalta (duloxetine) 
3.	Desyrel (trazodone) 
4.	Effexor (venlafaxine) 
5.	Edronax, Vestra (reboxetine) 
6.	Remeron (mirtazapine) 
7.	Serzone ( nefazodone) 
8.	Wellbutrin (bupropion) 
Selective Serotonin Reuptake Inhibitors (SSRIs)
The SSRIs are particularly helpful in heading off depression in the early stages, before it becomes deeply rooted. Recent studies suggest that SSRIs are ideal for those people with minor depressive illness -- much better than tricyclics, such as imipramine, or the complication-prone MAOIs. The SSRIs are certainly effective for major depression, too.
"Before taking Zoloft, I had a bad case of the blahs. Everything just seemed colorless. But now, sometimes I'll just lie in bed and rub the blanket between my fingers," says Sharon, 38. "It's not sexual, but my sensitivity is heightened. The feel-goodness goes right down into my bones."
Research seems to suggest that you can head off serious full-blown illness by taking an SSRI during the early stages of depression. These drugs work so well that someday soon, doctors may begin recommending early screening for depression, just as they now recommend early screening for breast cancer and high blood pressure.
This doesn't mean that SSRIs are the only worthwhile antidepressant, of course. There is still a place for the older drugs.
Researchers note that the SSRIs don't work for 20 percent to 40 percent of depressed or anxious people who try them -- the same failure rate as for the older antidepressants.

Most experts agree that no single SSRI is better than the rest, despite Prozac's image as a miracle drug that not only cures depression but can make many healthy people "better than well". Each drug has a certain profile of its own particular side effects; some have markedly similar side effects, while others vary widely.
For example, Zoloft and Paxil don't last as long in the body as Prozac; the half-life of Zoloft is about 26 hours, and the half-life of Paxil is about 21 hours. ("Half-life" is the time it takes for a drug in the blood to decrease by half of its original dose.) It's important to understand that all the SSRIs may cause nausea, headache, anxiety, dry mouth, insomnia, and a variety of sexual dysfunctions. But as mentioned, what makes Prozac less desirable is that it lingers in the body much longer than other SSRIs; up to six weeks after you stop taking the drug, traces of Prozac and its metabolites can still be found in your body. If you have a bad reaction to Zoloft or Paxil, symptoms last for a week or two. But side effects while taking Prozac can last for up to six weeks before all traces of the drug leave your body.
Of course, none of the SSRIs are any sort of wonder drug. They all have some side effects, although they are less severe than those of other antidepressants.
One of the biggest problems with these drugs is their cost. All of them are much more expensive than the generic versions of older drugs like MAOIs or tricyclics. Generic versions of the older drugs are available because their patents have expired.
No matter how wonderful a drug may be, if you can't afford it, it's not going to do you much good. The high cost of the SSRIs can be a real hardship for someone with no insurance, or whose insurance doesn't cover drugs. At about $2 to $3 per pill, the pharmacy bill can be overwhelming.
It's a problem for Mary, 28, whose health insurance covers all drugs except medications for mental health problems. "My psychiatrist is very aware of this problem," Mary explains. "He doesn't give me Zoloft alone because it would be too expensive. So he prescribes a smaller amount of Zoloft with desipramine (a less-expensive tricyclic)." The desipramine boosts the effects of Zoloft, and the combination costs less than a full dose of Zoloft alone.
Serotonin-Related Drugs
Serzone is the first of a new type of antidepressant manufactured by Bristol-Myers Squibb that has been approved by the FDA and is chemically different from other antidepressants.
Serzone combines the main mechanisms of two major classes of drugs -- the SSRIs and the tricyclics -- with fewer instances of at least two problematic side effects (insomnia and sexual dysfunction).
However, the FDA has cauutioned that direct comparisons between Serzone and other antidepressants have not yet been done, although it does not directly dispute the company's claims. Bristol-Myers bases its claims on figures in published reports of other drugs' side effects. 
Serzone is the first drug that boosts the brains' level of serotonin while blocking serotonin receptors. While clinical trials have found Serzone to be as effective at alleviating depression as other drugs, when taken twice a day it shows little problems of disturbing sleep. As many as one in five patients taking an SSRI are also prescribed some type of sleep aid. 
Sexual dysfunction may occur in SSRI users from one to five percent according to the drug companies (although actual incidence of the problem may be much higher, critics charge -- as high as 40 percent). The incidence of sexual problems among Serzone patients is cited at 1.5 percent, according to Bristol-Myers.
Medical Cautions   Severe kidney or liver disease could result in higher-than-normal blood levels of the SSRIs. In addition, the SSRIs may not be the best choice in the treatment of patients with mania, or in those with a history of seizures.
Side Effects  -The side effects of SSRIs are usually mild and manageable, although once in a while a sensitive person gets a severe reaction. Like most antidepressants, SSRIs may cause nausea, dizziness, or dry mouth, not to mention a range of sexual-function side effects, including decreased sexual interest (in men), increased sexual interest (in women), ejaculation problems, impotence, or menstrual changes. The most common side effects with Zoloft, launched in 1991, and Paxil, introduced in 1993, are insomnia, diarrhea, tremor, and drowsiness. If you get side effects while taking either of these, your doctor may switch you to Wellbutrin, as long as you don't have any of the conditions that might make you vulnerable to seizures with this drug (such as previous severe head injury or epilepsy). And like Prozac, Zoloft and Paxil can produce mild mania in some people with a genetic tendency in that direction.
Luvox (fluvoxamine) is an SSRI recently approved by the FDA for the treatment of obsessive-compulsive disorder but not yet approved for depression in this country. (It has been used as an antidepressant for several years in Europe and Canada.)
Drug Interactions Given together, tryptophan and any of the SSRIs may cause headache, nausea, sweating, and dizziness. Taking an SSRI within two weeks of an MAOI (such as Marplan or Parnate) may cause serious side effects; you should wait at least two weeks between stopping MAOIs and starting an SSRI, or at least five weeks after stopping an SSRI and starting an MAOI. Combining Paxil and warfarin may cause excess bleeding. If you're taking cimetidine, which can cause an increase in the blood levels of Paxil, your dosage of Paxil should be adjusted. Research suggests that Zoloft, unlike MAOIs or tricyclics, doesn't necessarily appear to cause problems when mixed with alcohol. However, Zoloft's manufacturers don't recommend the combination. There are no known dangerous reactions between nonprescription drugs and Zoloft, but because it's theoretically possible, be sure to talk to your doctor about any other drugs you take. Combining Zoloft with either digitoxin (Crystodigin) or warfarin (Coumadin) may cause unwanted side effects.
Pregnancy and Breast-Feeding  Most SSRIs haven't been studied in nursing mothers or pregnant women, but animal studies have suggested that Zoloft may cause developmental problems or decrease survival of offspring. Animal studies with Paxil haven't revealed any birth defects.
Other Disorders  The SSRIs may be an effective treatment for other disorders besides depression. Luvox appears to be as effective as Prozac or clomipramine for obsessive-compulsive disorder. Paxil has been approved by the FDA for obsessive-compulsive disorder and panic disorder. Zoloft has been approved for obsessive-compulsive disorder.
Withdrawal  Research with SSRIs has not found that people become dependent on the drug or have withdrawal symptoms when they stop taking it. Nevertheless, you should let your doctor know if you develop any troubling symptoms while taking, or after stopping, an SSRI. 
 Monoamine Oxidase Inhibitors
A good explanation of how MAOIs work, what makes them different from other antidepressants, and some of the side effects you might want to watch out for.
"MAO inhibitors worked much better for me than tricyclics. But for a chocoholic, the dietary restrictions were torture. That's why I finally stopped taking them."
-- Marie, 42 
Soon after scientists developed tricyclic antidepressants, another group of chemicals very different from the tricyclics rolled out of the laboratory -- the monoamine oxidase (MAO) inhibitors. These new drugs affected the same neurotransmitters (serotonin and norepinephrine) that the tricyclics did, but they also affected dopamine. 
How They Work-Once the brain's three neurotransmitters, known as monoamines (serotonin, norepinephrine, and dopamine), have played their part in sending messages in the brain, they get burned up by a protein in the brain called monoamine oxidase, a liver and brain enzyme.
Antidepressants known as monoamine oxidase inhibitors work by blocking this cleanup activity. When the excess neurotransmitters don't get destroyed, they start piling up in the brain. And since depression is associated with low levels of these monoamines, it's not surprising that increasing the monoamines ease depressive symptoms.
Unfortunately, monoamine oxidase doesn't just destroy those neurotransmitters; it's also responsible for mopping up another amine called tyramine, a molecule that affects blood pressure. So when monoamine oxidase gets blocked, levels of tyramine begin to rise, too. And that's when the trouble starts.
While a hike in neurotransmitters is beneficial, an increase in tyramine is disastrous. Excess tyramine can cause a sudden, sometimes fatal increase in blood pressure so severe that it can burst blood vessels in the brain.
Every time you eat chicken liver, aged cheese, broad-bean pods, or pickled herring, tyramine floods into your brain. Normally, MAO enzymes take care of this potentially harmful tyramine excess. But if you're taking an MAO inhibitor, the MAO enzyme can't stop tyramine from building up. This is exactly what happened when the drugs were introduced in the 1960s. Because no one knew about the tyramine connection, a wave of deaths from brain hemorrhages swept the country. Other patients taking MAO inhibitors experienced severe headaches caused by the rise in blood pressure. These early side effects were particularly disturbing because nobody knew why they were happening.
The mystery was solved when a British pharmacist noticed that his wife, who was taking MAO inhibitors, got headaches when she ate cheese. But the early MAOIs were considered so dangerous (they also can damage the liver, brain, and cardiovascular systems) that even after the MAO-tyramine connection was finally understood, these drugs were taken off the American market for a time. (A related European antidepressant drug, Deprenyl, is marketed in this country as an anti-Parkinson's medication; it requires less stringent dietary cautions.)
Eventually the MAOIs were reintroduced in this country despite the tyramine risk because some depressed people don't respond to any other medication. Nevertheless, MAO inhibitors are usually the antidepressant of last resort.
"I call it the 'St. Jude' drug," says psychiatrist Andy Myerson. "It's the drug I use when nothing else works and someone is willing to give up anything in the hope that something will help their depression."
Types of MAO Inhibitors and Their Dosages
MAO Inhibitor - isocarboxazid (Marplan)   Usual Starting Dose: 30 mg/day    Maximum Dose: 30 mg/day 
phenelzine (Nardil)    Usual Starting Dose: 15 mg/day     Maximum Dose: 60 mg/day
tranylcypromine (Parnate)   Usual Starting Dose: 30 mg/day    Maximum Dose: 60 mg/day
Prime Candidates -If you're very vulnerable to depression but don't suffer from the classic symptoms of major depression, MAOIs could be for you. They are especially good if you seem mildly depressed, if you become depressed more gradually, or if your primary complaints are boredom and apathy.
If you have atypical depression -- you're sensitive to rejection, overeat and oversleep, and react strongly to your environment -- you may respond very well to MAOIs, which can reduce the sensitivity that causes you to feel so easily hurt or rejected. Others who tend to respond very well to MAOIs can feel quite depressed, but they're able to surface from the morass of their depression from time to time and experience pleasure before plunging into depression again.
The MAOI phenelzine (Nardil) has been found specifically to help patients characterized as atypical. These patients often have mixed anxiety and depression, or depression with phobia or hypochondriacal features. There is less evidence that Nardil may be effective in severely depressed patients. Tranylcypromine (Parnate) is a good choice if you have major depression without melancholia.
Who Shouldn't Take MAOIs  If you've got serious heart problems, epilepsy, bronchitis, asthma, or high blood pressure, or if you resist following a stringent diet, MAOIs aren't for you. In addition, isocarboxazid (Marplan) may be too stimulating if you're hyperactive, agitated, or schizophrenic. Studies suggest that Nardil may not be as effective if you are severely depressed. Patients should wait at least two weeks when being transferred to Parnate from another MAO inhibitor.
Pros and Cons  One of the big problems with MAO inhibitors is that they make you feel drugged and sluggish. "I didn't respond to tricyclics at all five years ago," says Karen, a New Jersey graduate student who has been chronically depressed most of her life. "When I was switched to an MAOI, I responded very well. But I couldn't take the diet. After I finally went off the drug, my friends told me I was always in a daze while I was taking MAOIs, but I wasn't aware of that at the time. I was switched to Prozac four years ago, and I've been taking that ever since." Patients often look dazed or even robotic, much the way Karen had appeared to her friends. But what people really hate are the lists of dietary restrictions and potential side effects.
Dietary Restrictions Don't eat or drink any of the following when taking MAOIs unless your doctor advises otherwise: 
•	aged foods  alcoholic beverages (especially chianti, sherry, liqueurs, and beer)  alcohol-free or reduced-alcohol beer or wine  anchovies  bologna, pepperoni, salami, summer sausage, or any fermented sausage  caviar  cheeses (especially strong or aged varieties), except for cottage and cream cheese  chicken livers  fermented foods  figs (canned)  fruit: raisins, bananas (or any overripe fruit)  meat prepared with tenderizers; unfresh meat;  meat extracts   smoked or pickled meat, poultry, or fish   soy sauce 
Foods you can eat in moderation: 
•	avocados  beer   caffeine (including chocolate, coffee, tea, cola)   chocolate   raspberries   sauerkraut   soup   (canned or powdered)   sour cream   yogurt 
"A lot of patients are resentful about the diet they have to follow," explains Dr. Myerson. "They tend to blame the doctor when they can't eat their favorite foods, and many people simply won't follow the diet." Other mental health experts point out that MAO inhibitors often interfere with the relationship between doctor and patient, because people feel so resentful about their side effects and diet that they don't want to talk to their doctor during therapy.
Their relatively risky profile makes them a poor choice for potentially suicidal patients who might intentionally take an overdose. At very low doses, the MAOIs can have toxic effects on the heart, unlike Prozac, which is not considered toxic even at very high doses. Studies have shown that MAOIs are not associated at all with suicide in nonsuicidal patients, as opposed to most other antidepressants. In a 1991 Harvard University study of 1,017 depressed people, 63 nonsuicidal patients took an MAOI and none became suicidal.
On the other hand, there's no doubt that for a certain subset of people, the MAO inhibitors work better than any other antidepressant.
"I've seen a few miracle cures with these drugs," one psychiatrist noted. "And they're particularly good if people suffer from panic attacks in addition to depression." 
Furthermore, if you have hypertension or heart problems, the MAOIs might be for you because at therapeutic doses, they can lower blood pressure. In contrast to the tricyclic antidepressants, MAO inhibitors have little negative effect on heart rate.
If you were having problems with chest pain (angina) before taking MAO inhibitors, you may find that you're feeling much better now that you're taking this drug. Whatever you do, don't start running a few extra miles or working out a lot more at the gym without first discussing it with your doctor! Too much activity can bring on another attack of chest pain.
Before Taking MAOIs   Your doctor will probably quiz you about a range of medical conditions before prescribing an MAO inhibitor. It's especially important to tell your doctor if you have frequent headaches or chest pain. Since a severe headache or chest pain during MAOI therapy is the primary warning sign of a serious spike in blood pressure, anyone who normally gets severe headaches might overlook an important warning sign. 
Your doctor will want to know if you have diabetes mellitus (you may need to change your insulin level) or an alcohol problem, since drinking while taking MAOIs may cause serious side effects.
Also tell your doctor if you have heart or blood-vessel disease, liver or kidney problems, Parkinson's disease, or an overactive thyroid.
Side Effects  The one thing you've got to watch out for with these drugs is that sudden spike in blood pressure called a "hypertensive crisis" (also called the "cheese reaction") that we discussed at the beginning of this article. As long as you follow a strict tyramine-free diet (see "Dietary Restrictions" above), you should be able to avoid the risk.
Diet-Related Side Effects. Your doctor most assuredly will give you a list of prohibited foods. It's important to remember that the tyramine found in foods -- even a type of food that can be eaten in small quantities -- adds up. So while it's okay to eat small amounts of sour cream or artichokes, it would not be acceptable to eat a meal of sauerkraut with a sauce of yogurt and sour cream, followed by a dessert of raspberries and chocolate together with a cup of coffee.
It's also important to understand that while you may get away with eating a forbidden food once or twice, it may cause a reaction the third or fourth time. This is because a particular food doesn't always contain the same amount of tyramine.
The symptoms are as follows: severe headache radiating to the front of the head, stiff and/or sore neck, nausea and vomiting, sensitivity to light, dilated pupils, sweating (sometimes with fever or with cold, clammy skin), chest pain, or heart palpitations. A blood pressure rise usually occurs within several hours after taking the drug. Stop taking MAO inhibitors immediately if you get a severe headache or palpitations, then call your doctor.
Your doctor can give you a drug called Procardia as an emergency measure if you accidentally eat something that causes a reaction.
There is also a range of less serious side effects that accompany the MAOIs. Like all antidepressants, the MAOIs are capable of inducing a manic state in people who are manic-depressive. Like tricyclics, MAOIs have been reported to cause memory problems. Other possible side effects include:
Fainting and/or Dizziness. If you're taking an MAOI, you may feel a bit dizzy or faint if you stand up quickly. It's a common side effect with these drugs and is more annoying than anything else. It can lead to giddiness, muscular weakness, nausea, perspiration, hyperventilation, and sometimes confusion. If this happens to you, try standing up more slowly. (You may notice that you have a particular problem when you get up in the morning; this is because blood pressure is lowest then. If this happens, sit on the edge of the bed, dangling your feet for a minute or two, and then rise slowly.)
This problem often fades away with time. If it doesn't, you can try exercising your leg muscles to prevent blood from pooling in your legs. It may also help to wear support hosiery and drink plenty of fluids.
If the problem gets worse, ask your doctor if you can divide your medication into several doses to be taken during the day. Try taking the medicine after meals, and take salt tablets.
Drowsiness. Because MAO inhibitors may cause blurred vision, drowsiness, or a "drugged" feeling, be sure you know how you react to this medicine before you do anything that could be dangerous if your alertness or vision were affected, such as driving or operating machinery.
Diabetes. If you're a diabetic, MAO inhibitors may affect your blood sugar levels. While using these antidepressants, be very careful when you're testing the sugar levels in your blood or urine. Consult with your doctor if you have any questions about your diabetic condition.
Sexual Problems. Like many other antidepressants, MAOIs can cause a range of sexual problems. Of these, delayed orgasm is the most common (it is also very likely with Prozac). However, many people note that sexual problems eventually disappear.
Surgery. Be sure to tell your doctor or dentist that you're taking MAO inhibitors before any kind of surgery, dental treatment or emergency treatment -- even if you stopped taking the drug up to two weeks ago. The anesthesia combined with the MAOIs can cause a drop in blood pressure or other problems. You may want to carry an ID card noting that you're taking this medicine. If you're taking these drugs, you shouldn't agree to any elective surgery requiring general anesthesia.
Weight Gain. MAOIs are associated with some degree of weight gain. (Prozac and some other SSRIs do not seem to cause this side effect.) 
General Side Effects of all MAO Inhibitors   Stop taking this drug and seek immediate help for:
•	unusually high blood pressure  severe chest pain  severe headache   increased sweating  stiff or sore neck  fast or slow heartbeat  increased sensitivity to light  nausea and vomiting  
Check with your doctor if you have: severe diziness or light-headedness, especially when arising from a sitting or lying position  diarrhea  pounding heart  swelling of feet and/or lower legs  unusual excitement or nervousness  dark urine  fever  skin rash  slurred speech  sore throat  staggering walk  yellow eyes and/or skin 
Mild side effects not usually requiring medical attention: blurry vision  decreased sexual ability  urinary problems  drowsiness  mild headache  weight gain  increased sweating  restlessness  shakiness or  trembling  fatigue and weakness  sleeping problems  chills  constipation  decreased appetite  dry mouth  muscle twitching during sleep  increased appetite and mild dizziness or light-headedness 
Drug Interactions-  While aspirin, Tylenol (plain), Motrin, or antibiotics are safe when combined with MAOIs, you should check with your doctor before taking any other medicine.
There have been reports of serious -- sometimes fatal -- reactions when an MAO inhibitor is combined with Prozac. These reactions include high blood pressure, nausea and vomiting, fever, rigidity, rapidly fluctuating vital signs, shock, and mental changes. You shouldn't take Prozac until two weeks after stopping therapy with an MAO inhibitor. Even more important, because Prozac takes a long time to be eliminated from the body, you should wait at least five weeks after stopping Prozac before you start taking an MAO inhibitor.
Besides Prozac, there are some other medications that can provoke a hypertensive reaction similar to the cheese reaction (but not involving tyramine). Of these, the most dangerous are nonprescription cold, cough, or sinus medications such as Contac or Dristan; most of them contain decongestants (like pseudoephedrine). Other drugs on the danger list include weight-control pills and asthma inhalants. Illegal drugs like cocaine and amphetamines also cause this problem.
Most of the medications that cause problems are stimulants that can trigger an increase in the release of norepinephrine, which raises blood pressure. Since MAO metabolizes norepinephrine, people taking MAOIs have higher amounts of norepinephrine to be released, which raises the blood level of norepinephrine even more.
Drug Interactions and MAO Inhibitors    Some drugs should never be combined with MAO inhibitors, while others may be used if your doctor adjusts your dosage. It's extremely important for you to tell your doctor if you are taking any of the following drugs:
•	Allergy medicines (including nose drops or sprays)   Appetite suppressants    Antihistamines (Actifed DM, Benadryl, Benylin, Chlor-Trimeton, Compoz, etc.)    Antipsychotics    Antivert    Asthma drugs    Atrovent 
•	Blood-pressure medicine    Bucladin    BuSpar (may cause high blood pressure)   Cocaine (may severely increase blood pressure)  Cold medicines    Demerol (deaths have occurred when combining MAOIs and a single dose of meperidine)    Dextromethorphan (may cause brief episodes of psychosis or bizarre behavior)    Ditropan    Dopar, Larodopa     Flexeril     Insulin (MAOIs may change amount of insulin needed)    Ludiomil     Marezine     Monoamine oxidase inhibitors (other)    Norflex    Norpace    Phenergan    Pronestyl    Prozac (may cause high fever, rigidity, high blood pressure, mental changes, confusion and hypomania; at least five weeks should pass between stopping Prozac and starting an MAOI)     Quinidex   Ritalin    Sinus medicine    Symmetrel    Tegretol (may increase seizures)    Temaril (may increase chance of side effects)    Tricyclic antidepressants (using these drugs within two weeks of taking MAOIs may cause serious side effects including sudden fever, extremely high blood pressure, convulsions, and death)    Tryptophan (may cause disorientation, confusion, amnesia, delirium agitation, hypomanic signs, shivering)    Urispas    Wellbutrin (allow at least two weeks between stopping Wellbutrin and starting MAOIs) 
The opiate narcotics Demerol (meperidine) and dextromethorphan (found in cough or cold medicines usually labeled "DM") should also be avoided. And Parnate can interfere with the benefit of guanethidine, methyldopa, reserpine, and dopamine. Nardil shouldn't be taken with dopamine, epinephrine and norepinephrine, methyldopa, L-dopa, L-tryptophan, L-tyrosine or phenylalanine (contained in aspartame, also known as NutraSweet).
Overdose -  The MAO inhibitors are somewhat more dangerous drugs than other antidepressants when taken in excessive amounts -- far more so than newer drugs such as Prozac, Zoloft or Desyrel. Symptoms of overdose include severe anxiety, confusion, convulsions or seizures, cool clammy skin, severe dizziness, severe drowsiness, fast and irregular pulse, fever, hallucinations, severe headache, high or low blood pressure, muscle stiffness, breathing problems, severe sleeping problems, or unusual irritability. 
Tolerance- Some people develop a tolerance to MAO inhibitors. This could mean that the drug will work for you at first, but you could suddenly become depressed again in the middle of treatment. This sort of reaction is particularly disturbing because it sets off a plummeting depression that may not respond to any other antidepressant. Oddly, if you develop tolerance to an MAOI, the best solution may be to switch to another antidepressant for a few weeks, and then start taking the same MAOI again. This way, the drug may regain its effectiveness.
Withdrawal - Don't suddenly stop taking this medicine on your own. Your doctor will probably ask you to gradually taper off your dosage to avoid the risk of side effects. Once you do stop taking the drug, remember that you must continue to observe all of the dietary restrictions for at least two weeks, avoiding all of the same foods and beverages that you did when you were taking MAO inhibitors.
Pregnancy and/or Breast-feeding -Because Parnate (and most likely Marplan and Nardil) cross the placenta, you and your doctor should weigh the need for this drug against the risks to your unborn child. Nardil has been shown to have adverse effects in pregnant mice; in doses well above the human dose it has caused decreases in the number of healthy offspring. While researchers don't know for sure whether antidepressants cause birth defects in humans, women who take any type of antidepressant have about twice the rate of miscarriages during the first trimester of pregnancy. As with most antidepressants, safe use of MAO inhibitors during pregnancy hasn't been established, but one limited study in humans did suggest an increased risk of birth defects when MAOIs are taken during the first trimester.
In animals, MAO inhibitors slow the growth of newborns and make them more excitable when their mothers take very large doses during pregnancy.
When it comes to breast-feeding, Parnate is passed into breast milk, but it is not known if this is true of Marplan and Nardil. There haven't been any reports of problems in nursing infants whose mothers have taken MAO inhibitors.
MAOIs and Children- Because MAOIs are among the most risky of antidepressants, most experts don't recommend giving them to children under age 16. Animal studies indicate that these drugs may slow growth in the young.
MAOIs and the Elderly- Older patients are usually more sensitive than younger adults to the MAO inhibitors, and they may be more likely to experience dizziness or light-headedness. Because of the danger of an abrupt increase in high blood pressure (hypertensive crisis), the MAO inhibitors are often not prescribed for people over age 60, or for those with heart or blood-vessel diseases.
Parnate should not be routinely given to anyone over age 60 because of the possibility of damaged blood vessels and the risk of sudden high blood pressure; you should wait at least two weeks before being transferred from Parnate to another MAOI. In this event, the starting dose should be half the normal starting dose for the first week of therapy. 
Tricyclics        Imipramine         Amitriptyline         Doxepin         Nortriptyline         Protriptyline         Trimipramine
- Discussion:
     - anticholinergic crisis in w/ antidepressant overdose presents as:
           - mydriasis, blurred vision, urinary retention, dry mucous membranes,
                 constipation, ileus, sinus tachycardia, hyperthermia or hypothermia,
                 confusion, agitation, and hallucinations;
           - acidosis potentiates TCA toxicity;
                  - respiratory acidosis is treated w/ intubation and hyperventilation;
     - drug interactions:
           - anesthetic agents:
                 - combination of halothane, pancuronium, & tricyclic antidepressants,
                         can cause severe ventricular arrhythmias;
          - interaction w/ neuroleptic agents, 
                 - combination of drugs should be especially avoided in the elderly;
                 - least potent antipsychotics (Chlorpromazine & Thioridazine tend to
                        be most sedating and to have most anticholinergic effects;
                 - use of such drugs in combination w/ antidepressant that also has
                        high anticholinergic activity may cause toxic anticholinergic
                        reactions, including delirium;
                 - autonomic side effects are also relatively frequent w/ less
                        potent neuroleptics, & resultant hypotensive episodes may
                        predispose to falls, myocardial infarction, or CVA;
Amitryipyline/Elavil:
- Tricyclics
- for depression, peripheral neuropathy, chronic pain adjunct;
- Adult: begin 50-100mg PO qhs; can increase to 300mg qhs;
- Strong anticholenergic effects, urinary retension, sedation;
- Contraindicated with hypersensitivity, concomitant use of MAO inhibitors,
     disulfiram, use during acute recovery phase of MI, use of ETOH or other
     CNS depressants;
     - use with caution w/ patients with history of seizures, urinary retention, angle
           closure glaucoma, increased intraocular pressure, cardiovascular disorders,
           hyperthyroidism;
- Note Side Effects: Sedation: +++; Insomnia: 0; Anticholinergic Effects: +++;
    Orthostatic Hypotension: +++; Nausea: 0;
    - Also: Erythematous Maculopapular Rash;
- Peds: <12yrs; Initially 50-100 mg PO qhs; can increase to 300 mg qhs;

Clomipramine 
Brand Name: Anafranil- outside U.S., Brand Names also known as: Anafranil 25; Anafranil Retard; Anafranil SR; Clofranil; Clomifril; Clopress; Gromin; Placil
Description  Clomipramine hydrochloride (Anafranil) is a tricyclic antidepressant used to treat depression and obsessive-compulsive disorder (OCD). It may also be used to treat other conditions as determined by your doctor.
Pharmacology- Clomipramine (CMI) is presumed to influence obsessive and compulsive behaviors through its effects on serotonergic neuronal transmission. The actual neurochemical mechanism is unknown, but CMI's capacity to inhibit the reuptake of serotonin (5-HT) is thought to be important.
Indications and Usage-Clomipramine is indicated for the treatment of obsessions and compulsions in patients with Obsessive-Compulsive Disorder (OCD). The obsessions or compulsions must cause marked distress, be time-consuming, or significantly interfere with social or occupational functioning, in order to meet the DSM-III-R (circa 1989) diagnosis of OCD.
The effectiveness of clomipramine for long-term use (i.e. for more than 10 weeks) has not been systematically evaluated in placebo-controlled trials. The physician who elects to use clomipramine for extended periods should periodically re-evaluate the long term usefulness of the drug for the individual patient. 
Contraindications-Clomipramine is contraindicated in patients with a history of hypersensitivity to clomipramine or other tricyclic antidepressants.
Clomipramine HCl should not be given in combination, or within 14 days before or after treatment, with a monoamine oxidase (MAO) inhibitor. Hyperpyretic crisis, seizures, coma, and death have been reported in patients receiving such combinations.
Clomipramine is contraindicated during the acute recovery period after a myocardial infarction.
Clomipramine is contraindicated in patients with existing liver or kidney damage and should not be administered to patients with a history of blood dyscrasias. 
Clomipramine is contraindicated in patients with glaucoma, as the condition may be aggravated due to the atropine-like effects of the drug. 
Warnings –Seizures-Seizure was identified as the most significant risk of clomipramine use.-Caution should be used in administering clomipramine to patients with a history of seizures or other predisposing factors. e.g., brain damage of varying etiology, alcoholism, and concomitant use with other drugs that lower the seizure threshold.
Rare reports of fatalities in association with seizures have been reported by foreign post-marketing surveillance, but not in U.S. clinical trials. In some of these cases, clomipramine had been administered with other epileptogenic agents: in others, the patients involved had possibly predisposing medical conditions. Thus a causal association between clomipramine treatment and these fatalities has not been established.
Physicians should discuss with patients the risk of taking clomipramine HCl while engaging in activities in which sudden loss of consciousness could result in serious injury to the patient or others, e.g., the operation of complex machinery, driving, swimming, climbing.
Precautions-Suicide: Since depression is a commonly associated feature of OCD, the risk of suicide must be considered. Prescriptions for clomipramine HCl should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose.
Cardiovascular: Tricyclic antidepressants, particularly in high doses, have been reported to produce sinus tachycardia, changes in conduction time and arrhythmias. A few instances of unexpected death have been reported in patients with cardiovascular disorders. Myocardial infarction and stroke have also been reported with drugs of this class. Therefore, clomipramine should be administered with extreme caution to patients with a history of cardiovascular disease, especially those who have a history of conduction disorders, those with circulatory lability and elderly patients. It also has a hypotensive action which may be detrimental in these circumstances. In such cases, treatment should be initiated at low doses with progressive increases only if required and tolerated, and the patients should be under close surveillance at all dosage levels. Monitoring of cardiac function and the ECG is indicated in such patients. 
Psychosis, Confusion, And Other Neuropsychiatric Phenomena: Patients treated with clomipramine have been reported to show a variety of neuropsychiatric signs and symptoms including delusions, hallucinations, psychotic episodes, confusion, and paranoia. Because of the uncontrolled nature of many of the studies, its is impossible to provide a precise estimate of the extent of risk imposed by treatment with clomipramine. As with tricyclic antidepressants to which it is closely related, clomipramine may precipitate an acute psychotic episode in patients with unrecognized schizophrenia.
Mania/Hypomania: During premarketing testing of clomipramine in patients with affective disorder, hypomania or mania was precipitated in several patients. Activation of mania or hypomania has also been reported in a small proportion of patients with affective disorder treated with marketed tricyclic antidepressants, which are closely related to clomipramine.
Central Nervous System: More than 30 cases of hyperthermia have been recorded by nondomestic post-marketing surveillance systems. Most cases occurred when clomipramine was used in combination with other drugs. When clomipramine and a neuroleptic were used concomitantly, the cases were sometimes considered to be examples of a neuroleptic malignant syndrome. 
Sexual Dysfunction: The rate of sexual dysfunction in male patients with OCD who were treated with clomipramine in the premarketing experience was markedly increased compared with placebo controls (i.e., 42% experienced ejaculatory failure and 20% experienced impotence, compared with 2.0% and 2.6% respectively, in the placebo group). Approximately 85% of males with sexual dysfunction chose to continue treatment.
Weight Changes: In controlled studies of OCD, weight gain was reported in 18% of patients receiving clomipramine, compared with 1% of patients receiving placebo. In these studies, 28% of patients receiving clomipramine had a weight gain of at least 7% of their initial body weight, compared with 4% of patients receiving placebo. Several patients had weight gains in excess of 25% of their initial body weight. Conversely, 5% of patients receiving placebo had weight losses of at least 7% of their initial body weight.
Surgery: Prior to elective surgery with general anesthetics, therapy with clomipramine HCl should be discontinued for as long as is clinically feasible, and the anesthetist should be advised. 
Use in Concomitant Illness: As with closely related tricyclic antidepressants, clomipramine should be used with caution in the following:
•	Hyperthyroid patients or patients receiving thyroid medication, because of the possibility of cardiac toxicity; 
•	Patients with increased intraocular pressure, a history of narrow-angle glaucoma, or urinary retention, because of the anticholinergic properties of the drug; 
•	Patients with tumors of the adrenal medulla (e.g., pheochromocytoma, neuroblastoma) in whom the drug may provoke hypertensive crises; 
•	Patients with significantly impaired renal function. 
Withdrawal Symptoms: A variety of withdrawal symptoms have been reported in association with abrupt discontinuation of clomipramine, including dizziness, nausea, vomiting, headache, malaise, sleep disturbance, hyperthermia, and irritability. In addition, such patients may experience a worsening of psychiatric status. While the withdrawal effects of clomipramine have not been systematically evaluated in controlled trials, they are well known with closely related tricyclic antidepressants, and it is recommended that the dosage be tapered gradually and the patient monitored carefully during discontinuation 
Information for Patients:
Physicians are advised to discuss the following issues with patients for whom they prescribe clomipramine:
•	The risk of seizure 
•	The relatively high incidence of sexual dysfunction among males 
•	Since clomipramine HCl may impair the mental and/or physical abilities required for the performance of complex and hazardous tasks and since clomipramine HCl is associated with a risk of seizures, patients should be cautioned about the performance of complex and hazardous tasks 
•	Patients should be cautioned about using alcohol, barbiturates, or other CNS depressants concurrently, since clomipramine HCl may exaggerate their response to these drugs; 
•	Patients should notify their physician if they become pregnant or intend to become pregnant during therapy; 
•	Patients should notify their physician if they are breast-feeding. 
Use in Pregnancy-There are no adequate or well-controlled studies in pregnant women. Withdrawal symptoms, including jitteriness, tremor, and seizures, have been reported in neonates whose mothers had taken clomipramine until delivery. Clomipramine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Use in Children
The safety and effectiveness in children below the age of 10 have not been established. Therefore, specific recommendations cannot be made for the use of clomipramine in children under the age of 10.
Use in Elderly
No unusual age-related adverse events have been identified in this elderly population, but the data is insufficient to rule out possible age-related differences, particularly in elderly patients who have concomitant systemic illnesses or who are receiving other drugs concomitantly.
Drug Interactions-Patients should be warned that, while taking clomipramine, their responses to alcoholic beverages, other CNS depressants (e.g. barbiturates, benzodiazepines or general anesthetics) or anticholinergic agents (e.g. atropine, biperiden, levodopa) may be exaggerated. When tricyclic antidepressants are given in combinations with anticholinergics or neuroleptics with an anticholinergic action, hyperexcitation states or delirium may occur, as well as attacks of glaucoma. Tricyclic antidepressants should not be employed in combination with anti-arrhythmic agents of the quinidine type. 
Clomipramine should not be used with MAO inhibitors.
Since clomipramine may diminish or abolish the antihypertensive effects of guanethidine, clonidine, reserpine, methyldopa, patients requiring concomitant treatment for hypertension should be given antihypertensives of a different type (e.g. diuretics, beta-blockers). 
Clomipramine should be discontinued prior to elective surgery, for as long as clinically feasible, since little is known about the interaction between clomipramine and general anesthetics. 
If administered concomitantly with estrogens, the dose of clomipramine should be reduced since steroid hormones inhibit the metabolism of clomipramine. 
Because clomipramine is highly bound to serum proteins, the administration of clomipramine to patients taking other drugs that are highly bound to protein (i.e. warfarin, digoxin) may cause an increase in plasma concentrations of these drugs, potentially resulting in adverse effects. Conversely, adverse reactions may result from the displacement of protein bound clomipramine by other highly bound drugs. 
BEFORE USING THIS MEDICINE: INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. This includes carbamazepine, cimetidine, dicumarol, clonidine, mibefradil, paroxetine, tramadol, other medicines for depression or emotional disorders, and medicines for seizures. Inform your doctor of any other medical conditions including heart conditions, allergies, pregnancy, or breast-feeding. 
Adverse Reactions-The most commonly observed adverse events associated with the use of clomipramine HCl and not seen at an equivalent incidence among placebo-treated patients were gastrointestinal complaints, including dry mouth, constipation, nausea, dyspepsia, and anorexia; nervous system complaints, including somnolence, tremor, dizziness, nervousness, and myoclonus; genitourinary complaints, including changed libido, ejaculatory failure, impotence, and micturition disorder; and other miscellaneous complaints, including fatigue, sweating, increased appetite, weight gain, and visual changes. 
The following list of adverse reactions have also been observed with clomipramine. These are listed in order of decreasing frequency. 
Neurological: Extrapyramidal effects such as ataxia, also headache, delirium, speech disorders, muscle weakness, muscle hypertonia, tinnitus, paresthesias of the extremities, convulsions, EEG changes, hyperpyrexia. Peripheral neuropathy has been reported with other tricyclic antidepressants. 
Cardiovascular: Hypotension, particularly orthostatic hypotension with associated vertigo, sinus tachycardia, palpitations. A quinidine-like effect and other reversible ECG changes in patients with normal cardiac status (such as flattening or inversion of T-waves, depressed S-T segments). Arrhythmias, hypertension, conduction disorders (e.g. widening of QRS complex, PQ changes, bundle-branch block), syncope. 
Behavioral: Drowsiness, fatigue, restlessness, confusion accompanied by disorientation (particularly in geriatric patients and patients suffering from Parkinson's disease), anxiety states, agitation, sleep disturbances, insomnia, nightmares, aggravated depression, hypomania or manic episodes, disturbed concentration, visual hallucinations, impaired memory, aggressiveness, yawning, depersonalization, activation of latent psychosis, delusions. 
Hematologic: Leukopenia, agranulocytosis, thrombocytopenia, eosinophilia and purpura. One case of pancytopenia has been reported. 
Gastrointestinal: Vomiting, abdominal pain, diarrhea, taste perversion, elevated transaminases, obstructive jaundice, hepatitis with or without jaundice. 
Endocrine: Weight loss, breast enlargement and galactorrhea in the female, inappropriate antidiuretic hormone (ADH) secretion syndrome, gynecomastia in the male, changes in blood sugar levels, increase in prolactin levels, menstrual irregularity. 
Allergic: Allergic skin reactions (skin rash, urticaria), photosensitization, pruritus, edema, drug fever. 
Withdrawal Symptoms: Abrupt cessation of treatment with tricyclic antidepressants after prolonged administration may occasionally produce nausea, vomiting, abdominal pain, diarrhea, insomnia, nervousness, anxiety, headache and malaise. These symptoms are not indicative of addiction. 
Overdose -Since children may be more sensitive than adults to acute overdosage with tricyclic antidepressants, and since fatalities in children have been reported, effort should be made to avoid potential overdose particularly in this age group. 
Symptoms-Signs and symptoms vary in severity depending upon factors such as the amount of drug absorbed, the age of the patient, and the time elapsed since drug ingestion. Blood and urine levels of clomipramine may not reflect the severity of poisoning: they have chiefly a qualitative rather than quantitative value, and they are unreliable indicators in the clinical management of the patient. The first signs and symptoms of poisoning with tricyclic antidepressants are generally severe anticholinergic reactions. CNS abnormalities may include drowsiness, stupor, coma, ataxia, restlessness, agitation, delirium, severe perspiration, hyperactive reflexes, muscle rigidity, athetoid and choreiform movement, and convulsions. Cardiac abnormalities may include arrhythmia, tachycardia, ECG evidence of impaired conduction, and signs of congestive heart failure, and in very rare cases, cardiac arrest. Respiratory depression, cyanosis, hypotension, shock, vomiting, hyperpyrexia, mydriasis, oliguria or anuria, and diaphoresis may also be present.
Treatment
Patients in whom overdosage is suspected should be admitted to hospital without delay. No specific antidote is available and treatment is essentially symptomatic and supportive. Gastric lavage or aspiration should be performed promptly and is recommended up to 12 hours or even more after the overdose, since the anticholinergic effect of the drug may delay gastric emptying. Administration of activated charcoal may help to reduce absorption of the drug. As clomipramine is largely protein bound, forced diuresis, peritoneal dialysis and hemodialysis are unlikely to be of value. 
In the alert patient, the stomach should be emptied promptly by lavage. In the obtunded patient, the airway should be secured with a cuffed endotracheal tube before beginning lavage (do not induce emesis). Instillation of activated charcoal slurry may help reduce absorption of CMI.
External stimulation should be minimized to reduce the tendency for convulsions. If anticonvulsants are necessary, diazepam and phenytoin may be useful. Adequate respiratory exchange should be maintained, including intubation and artificial respiration, if necessary. Respiratory stimulants should not be used.
In severe hypotension or shock, the patient should be placed in an appropriate position and given a plasma expander, and, if necessary, a vasopressor agent by intravenous drip. The use of corticosteroids in shock is controversial and may be contraindicated in case of overdosage with tricyclic antidepressants. Digitalis may increase conduction abnormalities and further irritate an already sensitized myocardium. If congestive heart failure necessitates rapid digitalization, particular care must be exercised. Hyperpyrexia should be controlled by whatever external means are available, including ice packs and cooling sponge baths, if necessary. Hemodialysis, peritoneal dialysis, exchange transfusions, and forced diuresis have generally been reported as ineffective because of the rapid fixation of clomipramine in tissues.
The slow intravenous administration of physostigmine salicylate has been used as a last resort to reverse severe CNS anticholinergic manifestations of overdosage with tricyclic antidepressants; however, it should not be used routinely, since it may induce seizures and cholinergic crises.
Dosage-After you start taking this medicine, several weeks may pass before you feel the full benefit.-HOW TO USE THIS MEDICINE: 
Follow the directions for using this medicine provided by your doctor. 
•	Take this medicine with food to prevent upset stomach. 
•	Store this medicine at room temperature, away from heat and light. 
•	Continue to take this medicine even if you feel better. 
•	Do not miss any doses. If you miss a dose of this medicine, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. If you take 1 dose daily at bedtime, do not take the missed dose the next morning. 
Additional Information: If your symptoms do not improve after taking this medicine for 4 weeks, inform your doctor. Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children. 
Dosage should be individualized according to the requirements of each patient. Treatment should be initiated at the lowest recommended dose and increased gradually, noting carefully the clinical response and any evidence of intolerance. During the initial dose titration phase, the total daily dose of clomipramine should be divided and served with meals to reduce gastrointestinal side-effects. 
Steady-state plasma levels may not be achieved until 2 to 3 weeks after a dosage adjustment. It may thus be advisable to wait 2 to 3 weeks after the initial dose titration phase, before attempting further dosage adjustments. It should be kept in mind that a lag in therapeutic response usually occurs at the onset of therapy, lasting from several days to a few weeks. Increasing the dosage does not normally shorten this latent period and may increase the incidence of side effects. 
Adults-Initial Dosage: Clomipramine therapy should be initiated at daily doses of 25 mg. Dosage may be increased by 25 mg increments, as tolerated, at 3 to 4 day intervals up to a total daily dose of 150 mg by the end of 2 weeks. Thereafter, the dose may be gradually increased over a period of several weeks to 200 mg. Doses in excess of 200 mg daily are not recommended for outpatients. Occasionally, in more severely depressed hospitalized patients, dosages up to 300 mg daily may be required. 
Children & Adolescents-Initial Dosage:As with adults, the starting dose is 25 mg daily and should be gradually increased (also given in divided doses with meals to reduce gastrointestinal side effects) during the first 2 weeks, as tolerated, up to a daily maximum of 3 mg/kg or 100 mg, whichever is smaller. Thereafter, the dosage may be increased gradually over the next several weeks up to a daily maximum of 3 mg/kg or 200 mg, whichever is smaller. As with adults, after titration, the total daily dose may be given once daily at bedtime to minimize daytime sedation.
Elderly and Debilitated Patients: In general, lower dosages are recommended for these patients. Initially, 20 to 30 mg daily in divided doses is suggested, with very gradual increments, depending on tolerance and response. Blood pressure and cardiac rhythm should be checked frequently, particularly in patients who have unstable cardiovascular function. 
Maintenance/Continuation Treatment (Adults, Children, and Adolescents): While there are no systematic studies that answer the question of how long to continue clomipramine, OCD is a chronic condition and it is reasonable to consider continuation for a responding patient. Although the efficacy of clomipramine after 10 weeks has not been documented in controlled trials, patients have been continued in therapy under double-blind conditions for up to 1 year without loss of benefit. However, dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for treatment. During maintenance, the total daily dose may be given once daily at bedtime.
IF YOU WILL BE USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, be sure to obtain necessary refills before your supply runs out. 
How Supplied-Tablets: Anafranil is available as capsules of 10, 25, 50, and 75 mg for oral administration.-
Desipramine 
Brand Name: Norpramin -outside U.S., Brand Names also known as: Pertofrane
Description-Norpramin (Desipramine) is a tricyclic antidepressant used to treat depression. It may also be used to treat other conditions as determined by your doctor. 
Pharmacology-The anticholinergic actions of desipramine are responsible for many of the commonly observed side effects of the drug. Desipramine causes ECG changes which are seen most frequently in elderly patients. Desipramine is known to lower the convulsive threshold. 
Desipramine increases the percentage of Stage 4 sleep (deep sleep) and decreases the percentage of REM sleep. A partial recovery of REM sleep is seen after 3 to 5 weeks of drug administration. However, in spite of this recovery, a REM rebound occurs following rapid drug withdrawal, which is experienced as an increase in dreaming.
A significant antidepressant effect should not be expected before the end of the second week. 
Category of Use: Antidepressant; Antipanic Agent; Antineuralgic; Anticataplectic; Antibulimic
Indications and Usage-Norpramin (Desipramine) is used for the treatment of endogenous depressive illness, including the depressed phase of manic depressive illness, involutional melancholia and psychotic depression. It may also be indicated in the management of depression of a nonpsychotic degree such as in selected cases of depressive neurosis. Patients with transient mood disturbances or normal grief reaction are not expected to benefit from tricyclic antidepressants. 
Contraindications-Desipramine should not be given in conjunction with, or within 2 weeks of, treatment with a MAO inhibitor.
Hyperpyretic crises, severe convulsions and death have occurred in patients receiving MAO inhibitors and tricyclic antidepressants. When desipramine is substituted for an MAO inhibitor, at least 2 weeks should elapse between the treatments. Administration of desipramine should then be started cautiously and should be increased gradually. 
The drug is contraindicated in the acute recovery period following myocardial infarction or in cases of poorly controlled cardiac decompensation. It should not be used in those who have shown prior hypersensitivity to the drug. Cross-sensitivity between this and other dibenzazepines is a possibility. 
Warnings -Extreme caution should be used when desipramine is given in the following situations: 
1.	In patients with cardiovascular disease; 
2.	In patients with a history of urinary retention or glaucoma; 
3.	In patients with thyroid disease or those taking thyroid medication; 
4.	In patients with a history of seizure disorder. Desipramine has been shown to lower the seizure threshold. 
Children: Not recommended for pediatric use.
Do not stop taking this medicine without first checking with your doctor.
Precautions-Desipramine should be dispensed in the least possible quantities to depressed outpatients, since suicide has been accomplished with this class of drug.
Desipramine therapy in patients with manic-depressive (bipolar) illness may induce a hypomanic state after the depressive phase terminates. 
The drug may cause exacerbation of psychosis in schizophrenic patients.
Both elevation and lowering of blood sugar levels have been reported. 
ALCOHOL, HOT WEATHER, EXERCISE, AND FEVER can increase dizziness. To prevent dizziness or fainting, sit up or stand slowly, especially in the morning. Also, sit or lie down at the first sign of dizziness or weakness.
Desipramine may cause increased sensitivity to the sun. Avoid exposure to the sun, sunlamps, or tanning booths until you know how you react to this medicine. Use a sunscreen or protective clothing if you must be outside for a prolonged period.
BEFORE YOU HAVE ANY MEDICAL OR DENTAL TREATMENTS, EMERGENCY CARE, OR SURGERY, tell the doctor or dentist that you are using this medicine. 
BEFORE YOU BEGIN TAKING ANY NEW MEDICINE, either prescription or over-the-counter, check with your doctor or pharmacist. 
The effects of this medicine may last for 3 to 7 days after you stop taking it. Make sure you continue to follow the precautions during this time. 
Pregnancy & Nursing: Safety for use during pregnancy and nursing has not been established. It should be kept in mind when administering desipramine, the possible benefits must be weighed against the possible hazards to mother and child.
Interference with Cognitive or Motor Performance: Desipramine may cause drowsiness, dizziness, or lightheadedness. Using this medicine alone, with other medicines, or with alcohol may lessen your ability to drive or to perform other potentially dangerous tasks. Do not drive, operate machinery, or do anything else that could be dangerous until you know how you react to this medicine. 
Drug Interactions-Norpramin may potentiate the effect of a variety of drugs. Close supervision and careful adjustment of dosage are required when this drug is administered concomitantly with anticholinergic or sympathomimetic drugs. 
INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. This includes carbamazepine, cimetidine, dicumarol, clonidine, mibefradil, paroxetine, tramadol, other medicines for depression or emotional disorders, and medicines for seizures or thyroid conditions. Inform your doctor of any other medical conditions including heart conditions, allergies, pregnancy, or breast-feeding. 
Desipramine can exaggerate your response to alcoholic beverages or other CNS depressants.
Adverse Reactions-Side effects, that may go away during treatment, include dry mouth, constipation, urinary retention, blurred vision, drowsiness, dizziness, headache, nausea, unpleasant taste, or an increased appetite especially for sweets. If they continue or are bothersome, check with your doctor. If you notice other effects not listed above, contact your doctor, nurse, or pharmacist. 
Common side effects include: difficulty sleeping or drowsiness, dizziness, headache, nausea, stomach pain, or loss of appetite.
Physical/Psychological Dependence:
After prolonged administration, abrupt cessation of treatment may produce nausea, headache, and malaise. Gradual dosage reduction has been reported to produce, within two weeks, transient symptoms including irritability, restlessness, and dream and sleep disturbance. These symptoms are not indicative of addiction. Rare instances have been reported of mania or hypomania occurring within 2-7 days following cessation of chronic therapy with tricyclic antidepressants. 
Overdose -Signs and Symptoms -Symptoms of overdose may include flushing, fast or irregular heartbeat, dry mouth, drowsiness, confusion, agitation, enlarged pupils, seizures, and loss of consciousness. 
Treatment-If you or someone you know may have used more than the recommended dose of this medicine, contact your local poison control center or emergency room immediately.
The treatment for an overdosage is evacuation of the ingested material and/or the use of activated charcoal.
Physostigmine salicylate is presently considered the treatment of choice in the reversal of the more severe CNS and cardiovascular complications of poisoning from tricyclic antidepressants.
Prolonged observation of at least a week is strongly recommended since deaths attributed to arrhythmias have been reported many days following an apparent recovery from a tricyclic antidepressant overdose. 
Dosage-After starting use of this medicine, several weeks may pass before you feel the full benefit. DO NOT STOP TAKING THIS MEDICINE without checking with your doctor. 
If your symptoms do not improve after taking this medicine for 4 weeks, inform your doctor.
•	Follow the directions for using this medicine provided by your doctor. 
•	Store this medicine at room temperature, away from heat and light. 
•	Continue to take this medicine even if you feel better. Do not miss any doses. 
•	If you miss a dose of this medicine, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. If you take 1 dose daily at bedtime, do not take missed dose the next morning. 
Additional Information: Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children. 
Adults: The usual adult dose is 100 to 200 mg/day. In more severely ill patients, dosage may be further increased gradually to 300 mg/day if necessary. Dosages above 300 mg/day are not recommended. 
Elderly and Debilitated Patients: 25 to 100 mg daily. Dosage should be initiated at a lower level and increased according to tolerance and clinical response to a usual maximum of 100 mg daily. In more severely ill patients, dosage may be further increased to 150 mg/day. Doses above 150 mg/day are not recommended in these patients. 
Children: Not recommended for use in children. IF YOU WILL BE USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, be sure to obtain necessary refills before your supply runs out. How Supplied-10 mg, 25 mg, 50 mg, 75 mg, 100 mg tablets. Make sure you contact your doctor for a refill before you run out of the medication.
Doxepin/Sinequan:
- Tricyclic Antidepressant;
- Usual daily dose: 75-300 mg/day;
- Note Side Effects: Sedation: +++;Insomnia: 0; Anticholinergic: ++;
     Orthostatic-Hypotension: +++; Nausea: 0;
Brand Names: Adapin, Sinequan
Description-Doxepin hydrochloride is one of a class of psychotherapeutic agents known as dibenzoxepin tricyclic compounds. Tricyclic antidepressants are used to relieve mental depression and depression that sometimes occurs with anxiety.
Pharmacology-The mechanism of action of doxepin HCl is not definitely known. It is not a central nervous system stimulant nor a monoamine oxidase inhibitor. The current hypothesis is that the clinical effects are due, at least in part, to influences on the adrenergic activity at the synapses so that deactivation of norepinephrine by reuptake into the nerve terminals is prevented. 
Doxepin HCl is virtually devoid of euphoria as a side effect. Characteristic of this type of compound, doxepin HCl has not been demonstrated to produce the physical tolerance or psychological dependence associated with addictive compounds.
Indications and Usage-The drug is recommendend for:
•	Psychoneurotic patients with depression and/or anxiety. 
•	Depression and/or anxiety associated with alcoholism (not to be taken concomitantly with alcohol). 
•	Depression and/or anxiety associated with organic disease (the possibility of drug interaction should be considered if the patient is receiving other drugs concomitantly). 
•	Psychotic depressive disorders with associated anxiety including involutional depression and manic-depressive disorders. 
The target symptoms of psychoneurosis that respond particularly well to doxepin include anxiety, tension, depression, somatic symptoms and concerns, sleep disturbances, guilt, lack of energy, fear, apprehension and worry. 
Contraindications-Doxepin is contraindicated in individuals who have shown hypersensitivity to the drug or to other dibenzoxepin compounds. 
Doxepin is contraindicated in patients with glaucoma or a tendency to urinary retention. These disorders should be ruled out, particularly in older patients. 
Owing to lack of clinical experience in the pediatric population, doxepin is not recommended for use in children under 12 years of age.
Tricyclic agents are generally contraindicated during the acute recovery phase following myocardial infarction and in the presence of acute congestive heart failure, as well as in patients with a history of blood dyscrasias and severe liver disease. 
Warnings -Tricyclic antidepressant drugs, particularly when given in high doses, can induce sinus tachycardia, changes in conduction time and arrhythmias. There have been reports of unexpected death in patients with heart disease. Heart attacks and strokes have also been reported in people using Tricyclics.
Close supervision is required when doxepin is given to hyperthyroid patients or those receiving thyroid medication because of the possibility of cardiovascular toxicity. At doses above 150 mg/day, it may block the antihypertensive effect of guanethidine and related compounds. 
Usage in Pregnancy
Since there is no experience in pregnant women who have received this drug, safety in pregnancy has not been established. There has been a report of apnea and drowsiness occurring in a nursing infant whose mother was taking doxepin.
Precautions-Since drowsiness may occur with the use of this drug, patients should be warned of the possibility and cautioned against driving a car or operating dangerous machinery while taking the drug. Patients should also be cautioned that their response to alcohol may be potentiated.
Since suicide is an inherent risk in any depressed patient and may remain so until significant improvement has occurred, patients should be closely supervised during the early course of therapy. Prescriptions should be written for the smallest feasible amount. This type of patient should not have easy access to large quantities of doxepin. 
Should increased symptoms of psychosis or shift to manic symptomatology occur, it may be necessary to reduce dosage or add a major tranquilizer to the dosage regimen.
Tricyclic antidepressants may also give rise to paralytic ileus, particularly in the elderly and in hospitalized patients. Therefore, appropriate measures should be taken if constipation occurs. 
Do not have surgery or dental or emergency treatment unless you tell the doctor or dentist in charge that you are taking this medicine. 
Doxepin should be used with caution in patients with impaired liver function or with a history of hepatic damage or blood dyscrasias. Periodic blood counts and liver function tests should be performed when patients receive doxepin in large doses or over prolonged periods. 
Drug Interactions-MAO Inhibitors: Serious side effects and even death have been reported following the concomitant use of certain drugs with MAO inhibitors. Therefore, MAO inhibitors should be discontinued at least two weeks prior to the cautious initiation of therapy with doxepin. The exact length of time may vary and is dependent upon the particular MAO inhibitor being used, the length of time it has been administered, and the dosage involved.
Cimetidine: Cimetidine has been reported to produce clinically significant fluctuations in steady-state serum concentrations of various tricyclic antidepressants. Serious anticholinergic symptoms (i.e., severe dry mouth, urinary retention and blurred vision) have been associated with elevations in the serum levels of tricyclic antidepressant when cimetidine therapy is initiated. Additionally, higher than expected tricyclic antidepressant levels have been observed when they are begun in patients already taking cimetidine. In patients who have been reported to be well controlled on tricyclic antidepressants receiving concurrent cimetidine therapy, discontinuation of cimetidine has been reported to decrease established steady-state serum tricyclic antidepressant levels and compromise their therapeutic effects. 
Alcohol: It should be kept in mind that alcohol ingestion may increase the danger inherent in any intentional or unintentional doxepin HCl overdosage. This is especially important in patients who may use alcohol excessively.
BEFORE USING THIS MEDICINE: INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. This includes carbamazepine, cimetidine, dicumarol, clonidine, mibefradil, paroxetine, tramadol, other medicines for depression or emotional disorders, and medicines for seizures. Inform your doctor of any other medical conditions including heart conditions, allergies, pregnancy, or breast-feeding. 
Adverse Reactions-NOTE: Some of the adverse reactions noted below have not been specifically reported with doxepin use. However, due to the close pharmacological similarities among the tricyclics, the reactions should be considered when prescribing doxepin.
Anticholinergic Effects: Dry mouth, blurred vision, constipation, and urinary retention have been reported. If they do not subside with continued therapy, or become severe, it may be necessary to reduce the dosage. 
Central Nervous System Effects: Drowsiness is the most commonly noticed side effect. This tends to disappear as therapy is continued. Other infrequently reported CNS side effects are confusion, disorientation, hallucinations, numbness, paresthesias, ataxia, extrapyramidal symptoms, seizures, tardive dyskinesia, and tremor. 
Cardiovascular: Cardiovascular effects including hypotension, hypertension, and tachycardia have been reported occasionally.
Allergic: Skin rash, edema, photosensitization, and pruritus have occasionally occurred.
Hematologic: Eosinophilia has been reported in a few patients. There have been occasional reports of bone marrow depression manifesting as agranulocytosis, leukopenia, thrombocytopenia, and purpura.
Gastrointestinal: Nausea, vomiting, indigestion, taste disturbances, diarrhea, anorexia, and aphthous stomatitis have been reported.
Endocrine: Raised or lowered libido, testicular swelling, gynecomastia in males, enlargement of breasts and galactorrhea in the female, raising or lowering of blood sugar levels, and syndrome of inappropriate antidiuretic hormone secretion have been reported with tricyclic administration.
Other: Dizziness, tinnitus, weight gain, sweating, chills, fatigue, weakness, flushing, jaundice, alopecia, headache, exacerbation of asthma, and hyperpyrexia (in association with chlorpromazine) have been occasionally observed as adverse effects. 
Withdrawal Symptoms: Abrupt cessation of treatment with tricyclic antidepressants after prolonged administration may produce nausea, headache and malaise. These symptoms are not indicative of addiction. 
Overdose -Signs and Symptoms -Mild: Drowsiness, stupor, blurred vision, excessive dryness of mouth.-Severe: Respiratory depression, hypotension, coma, convulsions, cardiac arrhythmias and tachycardias.-Also: urinary retention (bladder atony), decreased gastrointestinal motility (paralytic ileus), hyperthermia (or hypothermia), hypertension, dilated pupils, hyperactive reflexes. 
Treatment-Mild: Observation and supportive therapy is all that is usually necessary.
Severe: Medical management of severe doxepin overdosage consists of aggressive supportive therapy. Arrhythmias should be treated with the appropriate antiarrhythmic agent. It has been reported that many of the cardiovascular and CNS symptoms of tricyclic antidepressant poisoning in adults may be reversed by the slow intravenous administration of 1 mg to 3 mg of physostigmine salicylate. Because physostigmine is rapidly metabolized, the dosage should be repeated as required. Convulsions may respond to standard anticonvulsant therapy, however, barbiturates may potentiate any respiratory depression. Dialysis and forced diuresis generally are not of value in the management of overdosage due to high tissue and protein binding of doxepin.
If the patient is conscious, gastric lavage, with appropriate precautions to prevent pulmonary aspiration, should be performed even though doxepin is rapidly absorbed. The use of activated charcoal has been recommended, as has been continuous gastric lavage with saline for 24 hours or more. An adequate airway should be established in comatose patients and assisted ventilation used if necessary. EKG monitoring may be required for several days, since relapse after apparent recovery has been reported. 
Deaths by deliberate or accidental overdosage have occurred with this class of drugs. Since the propensity for suicide is high in depressed patients, a suicide attempt by other means may occur during the recovery phase. The possibility of simultaneous ingestion of other drugs should also be considered. 
Dosage-HOW TO USE THIS MEDICINE:-After you start using this medicine, several weeks may pass before you feel the full benefit. -Follow the directions for using this medicine provided by your doctor. -Store this medicine at room temperature, away from heat and light. -Continue to take this medicine even if you feel better. Do not miss any doses. If you miss a dose of this medicine, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. If you take 1 dose daily at bedtime, do not take missed dose the next morning. -Additional Information: If your symptoms do not improve after taking this medicine for 4 weeks, inform your doctor. DO NOT SHARE THIS MEDICINE with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children.-IF YOU WILL BE USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, be sure to obtain necessary refills before your supply runs out. -For most patients with illness of mild to moderate severity, a starting daily dose of 75 mg is recommended. Dosage may subsequently be increased or decreased at appropriate intervals and according to individual response. The usual optimum dose range is 75 mg/day to 150 mg/day. 
In more severely ill patients higher doses may be required with subsequent gradual increase to 300 mg/day if necessary. Additional therapeutic effect is rarely to be obtained by exceeding a dose of 300 mg/day. 
In patients with very mild symptomatology or emotional symptoms accompanying organic disease, lower doses may suffice. Some of these patients have been controlled on doses as low as 25-50 mg/day.The total daily dosage of doxepin HCl may be given on a divided or once-a-day dosage schedule. If the once-a-day schedule is employed the maximum recommended dose is 150 mg/day. This dose may be given at bedtime. The 150 mg capsule strength is intended for maintenance therapy only and is not recommended for initiation of treatment. 
Antianxiety effect is apparent before the antidepressant effect. Optimal antidepressant effect may not be evident for two to three weeks.
How Supplied-Each capsule contains: Doxepin HCl equivalent to 10, 25, 50, 75, 100 and 150 mg of doxepin. 
IMIPRAMINE/TOFRANIL:  Imipramine-Brand Names: Tofranil, Janimine
outside U.S., Brand Names also known as: Antidep; Apo-Imipramine; Chrytemin; Daypress; Depsol; Depsonil; Ethipramine; Fronil; Imidol; Imimine; Imine; Imipramin; Imipramine Hcl; Imiprex; Imiprin; Impril; Medipramine; Melipramine; Mipralin; Novopramine; Primonil; Pryleugan; Sermonil; Sipramine; Surplix; Talpramin; Tofnil; Tofranil-PM; Venefon	
for depression; childhood enuresis; trycyclic antidepressant; Adult:
Hospitalized: Start at 100mg/24hr in divided doses; can increase over
several weeks to 250-300mg/24hr; Outpatient: Maintainance of
50-150mg/24hr in divided doses; not to exceed 300 mg/24hr; Do not use
with MAO inhibitors; less sedation that with Amitriptyline;  Note Side
Effects: Sedation: ++;Insomnia: 0; Anticholinergic: ++;Orthostatic
Hypotension: +++; Nausea: 0; Peds: Enuresis: >6hr old: Initially 10-25 mg
PO qhs; increase by 10-25 mg increments every 1-2 weeks until the desired
effect or maximum dose of 2.5 mg/kg/day; Antidepressant: 1.5 mg/kg/24hr
PO or IM in 3 DD with max of 5mg/kg/24hr;
Description-Imipramine (Tofranil, Janimine) is a tricyclic antidepressant used to treat depression. It may also be used to treat bedwetting (enuresis) in children (5 years & older).
Pharmacology-The mechanism of action of imipramine HCl is not definitely known. However, it does not act primarily by stimulation of the central nervous system. The clinical effect is hypothesized as being due to potentiation of adrenergic synapses by blocking uptake of norepinephrine at nerve endings. The mode of action of the drug in controlling childhood enuresis is thought to be apart from its antidepressant effect.
Indications and Usage-Depression: Imipramine (Tofranil, Janimine) is used for the relief of symptoms of depression. Endogenous depression is more likely to be alleviated than other depressive states. One to three weeks of treatment may be needed before optimal therapeutic effects are evident. 
Childhood Enuresis: May be useful as temporary adjunctive therapy in reducing enuresis in children aged 5 years and older, after possible organic causes have been excluded by appropriate tests. In patients having daytime symptoms of frequency and urgency, examination should include voiding cystourethrography and cystoscopy, as necessary. The effectiveness of treatment may decrease with continued drug administration.
Contraindications-Imipramine (Janimine, Tofranil) is contraindicated in patients known to be hypersensitive to it.
Monoamine Oxidase Inhibitors: The concomitant use of monoamine oxidase inhibiting compounds (MAOIs) is contraindicated. Hyperpyretic crises or severe convulsive seizures may occur in patients receiving such combinations. The potentiation of adverse effects can be serious, or even fatal. When it is desired to substitute imipramine in patients receiving a monoamine oxidase inhibitor, as long an interval should elapse as the clinical situation will allow, with a minimum of 14 days. Initial dosage should be low and increases should be gradual and cautiously prescribed. 
The drug is contraindicated during the acute recovery period after a myocardial infarction.
The possibility of cross-sensitivity to other tricyclic antidepressants/dibenzazepine compounds should be kept in mind.
Warnings -Children: A dose of 2.5 mg/kg/day of imipramine HCl should not be exceeded in childhood. ECG changes of unknown significance have been reported in pediatric patients with doses twice this amount. 
Extreme caution should be used when this drug is given to: patients with cardiovascular disease because of the possibility of conduction defects, arrhythmias, congestive heart failure, myocardial infarction, strokes and tachycardia. These patients require cardiac surveillance at all dosage levels of the drug.
Imipramine should be used with caution in hyperthyroid patients or those on thyroid medication because of the possibility of cardiovascular toxicity.
Patients with a history of seizure disorder should be cautious because this drug has been shown to lower the seizure threshold.
Patients receiving guanethidine, clonidine, or similar agents, need to be watched since imipramine may block the pharmacologic effects of these drugs.
Imipramine may produce urinary retention and should be used with caution in patients with urinary pathology, particularly in the presence of prostatic hypertrophy. 
Suicide/Overdose: Imipramine may enhance the CNS depressant effects of alcohol. Therefore, it should be kept in mind that the dangers inherent in a suicide attempt of accidental overdosage with the drug may be increased for the patient who uses excessive amounts of alcohol. 
Sulfa Allergies: (For the Injectable form only) Contains sodium sulfite and sodium bisulfite, that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people.
Precautions-An ECG recording should be taken prior to the initiation of larger-than-usual doses of imipramine and at appropriate intervals thereafter until steady state is achieved.
Elderly patients and patients with cardiac disease or a prior history of cardiac disease are at special risk of developing the cardiac abnormalities associated with the use of imipramine.
It should be kept in mind that the possibility of suicide in seriously depressed patients is inherent in the illness and may persist until significant remission occurs. Such patients should be carefully supervised during the early phase of treatment with imipramine, and may require hospitalization. Prescriptions should be written for the smallest amount feasible. 
Hypomanic or manic episodes may occur, particularly in patients with cyclic disorders. Such reactions may necessitate discontinuation of the drug. If needed, imipramine may be resumed in lower dosage when these episodes are relieved. 
An activation of the psychosis may occasionally be observed in schizophrenic patients and may require reduction of dosage and the addition of a phenothiazine.
Concurrent administration of imipramine with electroshock therapy may increase the hazards; such treatment should be limited to those patients for whom it is essential, since there is limited clinical experience.
Imipramine should be used with caution in patients with significantly impaired renal or hepatic function.
Patients taking imipramine should avoid excessive exposure to sunlight since there have been reports of photosensitization.
Both elevation and lowering of blood sugar levels have been reported with imipramine use. 
Lengthy treatment with tricyclic antidepressants can lead to an increased incidence of dental caries. 
Usage in Children: The effectiveness of the drug in children for conditions other than nocturnal enuresis (bedwetting) has not been established. The safety and effectiveness of the drug as temporary adjunctive therapy for nocturnal enuresis in children less than 6 years of age has not been established. Consideration should be given to instituting a drug-free period following an adequate therapeutic trial with a favorable response.
A dose of 2.5 mg/kg/day should not be exceeded in childhood. ECG changes of unknown significance have been reported in pediatric patients with doses twice this amount.
Pregnancy & Nursing: There have been no well-controlled studies conducted with pregnant women to determine the effect of imipramine on the fetus. However, there have been clinical reports of congenital malformations associated with the use of the drug. Although a casual relationship between these effects and the drug could not be established, the possibility of fetal risk from the maternal ingestion of imipramine cannot be excluded. Therefore, imipramine should be used in women who are or might become pregnant only if the clinical condition clearly justifies potential risk to the fetus.
Limited data suggest that imipramine is likely to be excreted in human breast milk. As a general rule, a woman taking a drug should not nurse since the possibility exists that the drug may be excreted in breast milk and be harmful to the child.
Interference with Cognitive or Motor Performance: Since imipramine may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks, such as operating an automobile or machinery, the patient should be cautioned accordingly.
Drug Interactions-Patients should be warned that, while taking imipramine their responses to alcoholic beverages, other CNS depressants (e.g., barbiturates, benzodiazepines or general anesthetics) or anticholinergic agents (e.g., atropine, biperiden, levodopa) may be exaggerated. When tricyclic antidepressants are given in combinations with anticholinergics or neuroleptics with an anticholinergic action, hyperexcitation states or delirium may occur, as well as attacks of glaucoma. Tricyclic antidepressants should not be employed in combination with anti-arrhythmic agents of the quinidine type. 
BEFORE USING THIS MEDICINE: INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. This includes carbamazepine, cimetidine, dicumarol, clonidine, mibefradil, paroxetine, tramadol, other medicines for depression or emotional disorders, and medicines for seizures. Inform your doctor of any other medical conditions including heart conditions, allergies, pregnancy, or breast-feeding. 
Caution should be exercised when imipramine is used with agents that lower blood pressure.
In occasional susceptible patients or in those receiving anticholinergic drugs (including antiparkinsonism agents) in addition, the atropine-like effects may become more pronounced (e.g., paralytic ileus). Close supervision and careful adjustment of dosage is required when imipramine is administered concomitantly with anticholinergic drugs.
Avoid the use of preparations, such as decongestants and local anesthetics, which contain any sympathomimetic amine (e.g., epinephrine, norepinephrine), since it has been reported that tricyclic antidepressants can potentiate the effects of catecholamines.
Imipramine should be discontinued prior to elective surgery for as long as clinically feasible, since little is known about the interaction between imipramine and general anesthetics. 
If administered concomitantly with estrogens, the dose of imipramine should be reduced since steroid hormones inhibit the metabolism of imipramine. 
Adverse Reactions-Although the listing which follows includes a few adverse reactions which have not been reported with this specific drug, the pharmacological similarities among the tricyclic antidepressant drugs require that each of the reactions be considered when imipramine is administered.
Cardiovascular: Orthostatic hypotension, hypertension, tachycardia, palpitation, myocardial infarction, arrhythmias, heart block, ECG changes, precipitation of congestive heart failure, stroke. king, feeling, and acting with excitement and activity you cannot control.
Psychiatric: Confusional states (especially in the elderly) with hallucinations, disorientation, delusions; anxiety, restlessness, agitation; insomnia and nightmares; hypomania; exacerbation of psychosis. 
Neurological: Numbness, tingling, paresthesias of extremities; incoordination, ataxia, tremors; peripheral neuropathy; extrapyramidal symptoms; seizures, alterations in EEG patterns; tinnitus. 
Anticholinergic: Dry mouth, and rarely, associated sublingual adenitis; blurred vision, disturbances of accommodation, mydriasis; constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary track. 
Allergic: Skin rash, petechiae, urticaria, itching, photosensitization, edema (general or of face and tongue); drug fever; cross-sensitivity with desipramine. 
Hematologic: Bone marrow depression including agranulocytosis; eosinophilia; purpura; thrombocytopenia. 
Gastrointestinal: Nausea and vomiting, anorexia, epigastric distress, diarrhea; peculiar taste, stomatitis, abdominal cramps, black tongue. 
Endocrine: Gynecomastia in the male; breast enlargement and galactorrhea in the female; increased or decreased libido, impotence; testicular swelling; elevation or depression of blood sugar levels; inappropriate antidiuretic hormone (ADH) secretion syndrome. 
Other: Jaundice (simulating obstructive); altered liver function; weight gain or loss; perspiration; flushing; urinary frequency; drowsiness; dizziness; weakness and fatigue; headache; parotid swelling; alopecia; proneness to falling. 
Drug Abuse and Dependence
Though not indicative of addiction, abrupt cessation of treatment after prolonged therapy may produce nausea, headache, malaise, and anxiety.
In enuretic children treated with imipramine the most common adverse reactions have been nervousness, sleep disorders, tiredness, and mild gastrointestinal disturbances. These usually disappear during continued drug administration or when dosage is decreased. Other reactions which have been reported include constipation, convulsions, anxiety, emotional instability, syncope, and collapse. All of the adverse effects reported with adult use should be considered.
Overdose -Signs and Symptoms -Children have been reported to be more sensitive than adults to an acute overdosage of imipramine hydrochloride. An acute overdose of any amount in infants or young children, especially, must be considered serious and potentially fatal.
Symptoms of an overdose may vary in severity depending upon factors such as the amount of drug absorbed, the age of the patient, and the interval between drug ingestion and the start of treatment.
CNS abnormalities may include drowsiness, stupor, coma (loss of consciousness), ataxia, restlessness, agitation, hyperactive reflexes, muscle rigidity, athetoid and choreiform movements, and convulsions.
Cardiac abnormalities may include arrhythmia, tachycardia (fast or irregular heartbeat), ECG evidence of impaired conduction, and signs of congestive failure. Respiratory depression, cyanosis, hypotension, shock, vomiting, hyperpyrexia, mydriasis, and diaphoresis may also be present. 
Other symptoms of overdose may include flushing, dry mouth, drowsiness, confusion, agitation, enlarged pupils, seizures.
Treatment
If you or someone you know may have used more than the recommended dose of this medicine, contact your local poison control center or emergency room immediately.
Because CNS involvement, respiratory depression and cardiac arrhythmia can occur suddenly, hospitalization and close observation may be necessary, particularly with children, even when the amount ingested is thought to be small or the initial degree of intoxication appears slight or moderate.
All patients with ECG abnormalities should have continuous cardiac monitoring and be closely observed until well after cardiac status has returned to normal; relapses may occur after apparent recovery. 
Maintain adequate airway, empty stomach contents, and treat symptomatically.
Dosage-After you start using this medicine, several weeks may pass before you feel the full benefit. If your symptoms do not improve after taking this medicine for 4 weeks, inform your doctor.-Follow the directions for using this medicine provided by your doctor. -Store this medicine at room temperature, away from heat and light. Take this medicine everyday at evenly spaced intervals. If you miss a dose of this medicine, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. If you take 1 dose daily at bedtime, do not take missed dose the next morning. Additional Information: Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children. Discontinuation: The effects of this medicine may last for 3 to 7 days after you stop taking it. Continue to follow the warnings during this time. IF YOU WILL BE USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, be sure to obtain necessary refills before your supply runs out. Lower dosages are recommended for elderly patients and adolescents. Lower dosages are also recommended for outpatients as compared to hospitalized patients who will be under close supervision. Dosage should be initiated at a low level and increased gradually, noting carefully the clinical response and any evidence of intolerance. Following remission, maintenance, medication may be required for a longer period of time, at the lowest dose that will maintain remission.
Hospitalized patients: Initially, 100 mg/day in divided doses gradually increased to 200 mg/day as required. If no response after two weeks, increase to 250-300 mg/day. Outpatients: Initially 75 mg/day increased to 150 mg/day. Dosages over 200 mg/day are not recommended. Maintenance, 50-150 mg/day. Adolescent and geriatric patients: Initially, 30-40 mg/day; it is generally not necessary to exceed 100 mg/day.
Childhood Enuresis-Initially, an oral dose of 25 mg/day should be tried in children aged 5 and older. Medication should be given one hour before bedtime. If a satisfactory response does not occur within one week, increase the dose to 50 mg nightly in children under 12 years; children over 12 may receive up to 75 mg nightly. A daily dose greater than 75 mg does not enhance efficacy and tends to increase side effects. Evidence suggests that in early night bedwetters, the drug is more effective given earlier and in divided amounts, i.e., 25 mg in midafternoon, repeated at bedtime. Consideration should be given to instituting a drug-free period following an adequate therapeutic trial with a favorable response. Dosage should be tapered off gradually rather than abruptly discontinued; this may reduce the tendency to relapse. Children who relapse when the drug is discontinued do not always respond to a subsequent course of treatment.
A dose of 2.5 mg/kg/day should not be exceeded. ECG changes of unknown significance have been reported in pediatric patients with doses twice this amount.
The safety and effectiveness of imipramine as temporary adjunctive therapy for nocturnal enuresis in children less than 5 years of age has not been established.

Maprotiline-Brand Name: Ludiomil-outside U.S., Brand Names also known as: Loxapac—
Description-Maprotiline (Ludiomil) is an antidepressant used to treat depression with or without anxiety.
Pharmacology-Maprotiline has been shown to exhibit an antidepressant action. It strongly inhibits the uptake of noradrenaline in the brain and peripheral tissues, though it is notable in its lack of inhibition of serotonergic uptake. Maprotiline also exerts a sedative effect on the anxiety component of depressive illness. 
Similar to other tricyclic antidepressants, maprotiline lowers the convulsive threshold. 
Following repeated daily doses of maprotiline, a plasma steady state concentration was reached in the second week, with the majority of subjects receiving daily doses of 150 mg attaining steady state blood levels between 100 and 400 ng/mL.
Indications and Usage-Ludiomil is used to treat depression, including the depressed phase of manic-depressive illness (bipolar disorder), psychotic depression (unipolar depression), and involutional melancholia. It might also be useful in selected patients suffering severe depressive neurosis. 
Contraindications-Maprotiline should not be given in conjunction with, or within 14 days of treatment with a MAO inhibitor. Combined therapy of this type could lead to the appearance of serious interactions such as hyperpyrexia, tremors, generalized clonic convulsions, delirium and possible death. 
Contraindicated in patients with a history of hypersensitivity to Maprotiline.
Maprotiline is contraindicated during the acute recovery phase following myocardial infarction in the presence of acute congestive heart failure, and in patients with conduction defects. 
Should not be used in patients with known or suspected convulsive disorders. Maprotiline lowers the seizure threshold.
Patients with narrow angle glaucoma should not be given maprotiline.
Patients with urinary retention due to prostatic disease should not receive maprotiline. 
Maprotiline should be withdrawn in cases of acute poisoning with alcohol, hypnotics, analgesics or psychotropic drugs. 
Warnings -Cardiovascular: Tricyclic and tetracyclic antidepressants, particularly in high doses, have been reported to produce arrhythmias. A few instances of unexpected death have been reported in patients with cardiovascular disorders. Myocardial infarction and stroke have also been reported with these drugs. Therefore, extreme caution should be used when maprotiline is given to elderly patients, or those with known cardiovascular disease including those with a history of myocardial infarction, arrhythmias and/or ischemic heart disease.
Maprotiline should be used with caution in hyperthyroid patients and in those on thyroid medication because of the possibility of cardiovascular toxicity.
Maprotiline should be used with caution in patients receiving guanethidine or similar sympatholytic antihypertensive agents (bethanidine, reserpine, alpha-methyldopa, clonidine) since it may block the effects of these drugs with subsequent loss of blood pressure control. 
Seizures: Seizures have been reported in patients without a known history of seizures who were treated with maprotiline at therapeutic dose levels.
The risk of seizures may be increased when maprotiline is taken concomitantly with phenothiazines, when the dosage of benzodiazepines is rapidly tapered in patients receiving maprotiline, or when the recommended dosage of maprotiline is rapidly exceeded.
The risk of seizures may be reduced by: initiating therapy at a low dosage; maintaining the initial dosage for 2 weeks before raising it gradually in small increments.
Because of its anticholinergic properties, maprotiline should be used with caution in patients with a history of increased intraocular pressure or history of urinary retention, particularly in the presence of prostatic hypertrophy. 
Psychosis: An activation of psychosis has occasionally been observed in schizophrenic patients administered tricyclic antidepressant drugs and must be considered as a possibility when administering maprotiline. 
Hypomanic or manic episodes: in patients with cyclic disorders have been known to occur during treatment of a depressed phase with a tricyclic antidepressant. These 2 conditions, should they occur, may require a reduction in the dosage of maprotiline, discontinuation of the drug, and/or administration of an antipsychotic agent. 
Precautions-Suicide: The possibility of suicide in seriously depressed patients is inherent in their illness and may persist until significant remission occurs. Therefore, patients must be carefully supervised during all phases of treatment with maprotiline and prescriptions should be written for the smallest amount consistent with good management. 
Cardiovascular: Particularly in patients with heart diseases, as well as in elderly subjects, cardiac function should be monitored and ECG examinations performed during long-term treatment with high doses. Regular measurements of the blood pressure are called for in patients susceptible to postural hypotension. 
Constipation: Tricyclic antidepressants may give rise to paralytic ileus, particularly in the elderly and in hospitalized patients. Therefore, since maprotiline has similar anticholinergic properties, appropriate measures should be taken if constipation occurs. 
Usage in Children: The drug is not recommended for use in children.
Pregnancy & Nursing: Safe use of Maprotiline during pregnancy or lactation has not been established; therefore, its use in pregnancy, in nursing mothers or in women of childbearing potential requires that the benefits of treatment be weighed against the possible risks to mother and child. 
Interference with Cognitive or Motor Performance: Since Maprotiline may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks, such as operating an automobile or machinery, the patient should be cautioned accordingly.
Prior to elective surgery: Little is known about the interaction between maprotiline and general anesthetics. Maprotiline should be discontinued for as long as clinically feasible.
Drug Interactions-Maprotiline should not be given in conjunction with, or within 14 days of treatment with a MAO inhibitor. Combined therapy of this type could lead to the appearance of serious interactions such as hyperpyrexia, tremors, generalized clonic convulsions, delirium and possible death. 
While taking maprotiline, responses to alcoholic beverages, barbiturates, and other CNS depressants may be exaggerated. 
Maprotiline may diminish or abolish the antihypertensive effects of adrenergic neuron blocking drugs, such as guanethidine, bethanidine, reserpine, clonidine and alpha-methyldopa. Therefore, patients requiring concomitant treatment for hypertension should be given antihypertensives of a different type (i.e., diuretics, vasodilators, or beta-blockers which do not undergo pronounced biotransformation). 
Maprotiline may potentiate the cardiovascular effects of indirect and directly acting sympathomimetic drugs such as noradrenaline, adrenaline, and methylphenidate. Maprotiline may also potentiate the effects of anticholinergic drugs (atropine, biperiden) and levodopa. Therefore, close supervision and careful adjustment of dosage is required when administering maprotiline with anticholinergic or sympathomimetic drugs because of the possibility of additive effects. 
Drugs that activate hepatic microsomal enzymes, such as barbiturates, phenytoin, oral contraceptives and carbamazepine, may accelerate the metabolism of maprotiline resulting in decreased antidepressant efficacy. If necessary, the dosage should be adapted accordingly. 
Concomitant treatment with maprotiline and major tranquilizers may result in increased plasma levels of maprotiline, a lowered convulsion threshold, and seizures. 
The combination of maprotiline and benzodiazepines may cause increased sedation. 
Concurrent use of parenteral magnesium sulfate and maprotiline may result in serious potentiation of CNS depressant effects. 
BEFORE USING THIS MEDICINE: INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. This includes other medicines to treat depression. Inform your doctor of any other medical conditions including a recent heart attack, epilepsy, allergies, pregnancy, or breast-feeding. 
Adverse Reactions-This medicine may cause blurred vision, especially during the first few weeks of treatment.-Adverse reactions with maprotiline have been mild and transient, usually disappearing with continued treatment or following a reduction in the dosage.
Check with your doctor as soon as possible if any of the following side effects occur: More common: Skin rash, redness, swelling, or itching.
Less common: Constipation (severe); nausea or vomiting; shakiness or trembling; seizures (convulsions); unusual excitement; weight loss. 
Rare: Breast enlargement—in males and females; confusion (especially in the elderly); difficulty in urinating; fainting; hallucinations (seeing, hearing, or feeling things that are not there); inappropriate secretion of milk—in females; irregular heartbeat (pounding, racing, skipping); sore throat and fever; swelling of testicles; yellow eyes or skin.
Other common side effects are: Blurred vision; decreased sexual ability; dizziness or lightheadedness (especially in the elderly); drowsiness; dryness of mouth; headache; increased or decreased sexual drive; tiredness or weakness; constipation (mild); diarrhea; heartburn; increased appetite and weight gain; increased sensitivity of skin to sunlight; increased sweating; trouble in sleeping; weight loss.
Overdose -Signs and Symptoms -Symptoms of an overdose are convulsions (seizures); dizziness (severe); drowsiness (severe); fast or irregular heartbeat; fever; muscle stiffness or weakness (severe); restlessness or agitation; trouble in breathing; vomiting; and dilated pupils.
Treatment-If you or someone you know may have used more than the recommended dose of this medicine, contact your local poison control center or emergency room immediately.
No specific antidote is known.
Maintain adequate airway, empty stomach contents, and treat symptomatically.
Cardiac arrhythmias and CNS involvement pose the greatest threat and may occur suddenly even when initial symptoms appear to be mild. Therefore, patients who may have ingested an overdosage of maprotiline, particularly children, should be hospitalized and kept under close surveillance. 
Dosage-Several days to weeks may pass before you feel the full benefit of this medicine. Do not stop taking this medicine without checking with your doctor. -Follow the directions for using this medicine provided by your doctor. -Store this medicine at room temperature, in a tightly-closed container, away from heat and light. Continue to take this medicine even if you feel better. Do not miss any doses. If you miss a dose of this medicine, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. Additional Information: Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children. Patients should be kept under medical surveillance during treatment with maprotiline. The dosage of maprotiline should be individualized according to the requirements of each patient. Sometimes this medicine must be taken for up to 2 or 3 weeks before you begin to feel better. Adults: At first, 25 milligrams (mg) taken one to three times a day. Your doctor may increase your dose as needed. However, the dose is usually not more than 150 mg a day, unless you are in the hospital. Some hospitalized patients may need higher doses. (a higher initial dose of 100 mg daily in 2 or 3 divided doses may be indicated. The usual optimal dose in these patients is 150 mg daily, but some patients may require up to 225 mg in divided doses).When these higher doses are used, it is essential to exclude a history of convulsive disorders.
Elderly and Debilitated Patients: In general, lower dosages are recommended for these patients, and doses should only be increased in gradual increments. Initially, 10 mg 3 times daily is suggested, with very gradual increments, depending on tolerance and response, up to 75 mg daily in divided doses.
Children: This medicine is not recommended for use in children.
Discontinuation: After you stop taking this medicine, your body will need time to adjust. This usually takes about 3 to 10 days. Continue to follow the precautions listed above during this period of time.
How Supplied-Tablets: available in 25 mg, 50 mg, 75 mg. -IF YOU WILL BE USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, be sure to obtain necessary refills before your supply runs out. 
Nortriptyline/Aventyl:
- Discussion:
     - for endogenous depression; tricyclic antidepressant;
     - adult: 50-100mg PO qhs;
     - increase to 300 mg/day if needed;
     - note many anticholinergic side effects including blurred vision; urinary retention, dry mouth;
     - as compared to other tricyclic antidepressants, nortriptyline has mild-moderate sedative effects, and minimal side effects w/ regard to orthostatic hypotension and nausea;
PROTRIPTYLINE/VIVACTIL:
     for endogenous depression; tricyclic antidepressant; Adult: 5-10mg
PO tid/qid; Monitor elderly patients for cardiovascular side effects;
anticholinergic effects;
Bupropion-Brand Name: Wellbutrin
WELLBUTRIN (bupropion hydrochloride), an antidepressant of the aminoketone class, is chemically unrelated to tricyclic, tetracyclic, selective serotonin re-uptake inhibitor, or other known antidepressant agents. Its structure closely resembles that of diethylpropion; it is related to phenylethylamines. It has a bitter taste and produces the sensation of local anesthesia on the oral mucosa. 
Pharmacology-The neurochemical mechanism of the antidepressant effect of bupropion is not known. Bupropion does not inhibit monoamine oxidase. Compared to classical tricyclic antidepressants, it is a weak blocker of the neuronal uptake of serotonin and norepinephrine; it also inhibits the neuronal re-uptake of dopamine to some extent. 
In humans, following oral administration of bupropion, peak plasma bupropion concentrations are usually achieved within 2 hours.
Indications and Usage-Bupropion (Wellbutrin) is indicated for the treatment of depression. A physician considering bupropion for the management of a patient's first episodes of depression should be aware that the drug may cause generalized seizures with an approximate incidence of 0.4% (4/1000). This incidence of seizures may exceed that of other marketed antidepressants by as much as fourfold. This relative risk is only an approximate estimate because no direct comparative studies have been conducted. 
Effectiveness of bupropion in long-term use, that is, for more than 6 weeks, has not been systematically evaluated in controlled trials. Therefore, the physician who elects to use bupropion for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient. 
Contraindications-Bupropion is contraindicated in patients with a seizure disorder. Bupropion is also contraindicated in patients with a current or prior diagnosis of bulimia or anorexia nervosa because of a higher incidence of seizures noted in such patients treated with bupropion. The concurrent administration of bupropion and a monoamine oxidase (MAO) inhibitor is contraindicated. At least 14 days should elapse between discontinuation of an MAO inhibitor and initiation of treatment with bupropion. Bupropion is contraindicated in patients who have shown an allergic response to it. 
Warnings -Seizures: Bupropion is associated with seizures in approximately 0.4% (4/1000) of patients treated at doses up to 450 mg/day. This incidence of seizures may exceed that of other marketed antidepressants by as much as fourfold. This relative risk is only an approximate estimate because no direct comparative studies have been conducted. The estimate seizure incidence for bupropion increases almost tenfold between 450 and 600 mg/day, which is twice the usually required daily dose (300 mg) and one and one-third the maximum recommended daily dose (450 mg). Given the wide variability among individuals and their capacity to metabolize and eliminate drugs, this disproportionate increase in seizure incidence with dose incrementation calls for caution in dosing. –
In trial studies: The risk of seizure appears to be strongly associated with dose and the presence of predisposing factors. A significant seizure, CNS tumor, concomitant medications that lower seizure threshold, etc.) was present in approximately one-half of the patients experiencing a seizure. Sudden and large increments in dose may contribute to increased risk. While many seizures occurred early in the course of treatment, some seizures did occur after several weeks at fixed dose. 
Recommendations for reducing the risk of seizure: Retrospective analysis of clinical experience gained during the development of bupropion suggests that the risk of seizure may be minimized if (1) the total daily dose of bupropion does not exceed 450 mg, (2) the daily dose is administered t.i.d., with each single dose not to exceed 150 mg to avoid high peak concentrations of bupropion and/or its metabolites, and (3) the rate of incrementation of dose is very gradual. Extreme caution should be used when bupropion is (1) administered to patients with a history of seizure, cranial trauma, or other predisposition(s) toward seizure, or (2) prescribed with other agents (e.g., antipsychotics, other antidepressants, etc.) or treatment regimens (e.g., abrupt discontinuation of a benzodiazepine) that lower seizure threshold. 
Precautions-Agitation and Insomnia: A substantial proportion of patients treated with bupropion experience some degree of increased restlessness, agitation, anxiety, and insomnia, especially shortly after initiation of treatment. In clinical studies, these symptoms were sometimes of sufficient magnitude to require treatment with sedative/hypnotic drugs. In approximately 2% of patients, symptoms were sufficiently severe to require discontinuation of treatment with bupropion. 
Psychosis, Confusion, and Other Neuropsychiatric Phenomena: Patients treated with bupropion have been reported to show a variety of neuropsychiatric signs and symptoms including delusions, hallucinations, psychotic episodes, confusion, and paranoia. Because of the uncontrolled nature of many studies, it is impossible to provide a precise estimate of the extent of risk imposed by treatment with bupropion. In several cases, neuropsychitric phenomena abated upon dose reduction and/or withdrawal of treatmen
Activation of Psychosis and/or Mania: Antidepressants can precipitate manic episodes in Bipolar Manic Depressive patients during the depressed phase of their illness and may activate latent psychosis in other susceptible patients. Bupropion is expected to pose similar risks. 
Altered Appetite and Weight: A weight loss of greater than 5 pounds occurred in 28% of patients receiving bupropion. This incidence is approximately double that seen in comparable patients treated with tricyclics or placebo. Furthermore, while 34.5% of patients receiving tricyclic antidepressants gained weight, only 9.4% of patients treated with bupropion did. Consequently, if weight loss is a major presenting sign of a patient's depressive illness, the anorectic and/or weight reducing potential of bupropion should be considered. 
Suicide: The possibility of a suicide attempt is inherent in depression and may persist until significant remission occurs. Accordingly, prescriptions for bupropion should be written for the smallest number of tablets consistent with good patient management. 
Drug Interactions-No systematic data have been collected on the consequences of the concomitant administration of bupropion and other drugs. 
Studies in animals demonstrate that the acute toxicity of buproprion is enhanced by the MAO inhibitor phenelzine.
Concurrent administration of bupropion and agents which lower seizure threshold should be undertaken only with extreme caution (see WARNINGS). Low initial dosing and small gradual dose increases should be employed. 
BEFORE USING THIS MEDICINE: INFORM YOUR DOCTOR OR PHARMACIST of all prescription and over-the-counter medicine that you are taking. This includes monoamine oxide (MAO) inhibitors, HIV protease inhibitors, and Zyban. Inform your doctor of any other medical conditions including seizures, allergies, pregnancy, or breast-feeding. 
Pregnancy & Nursing:-There are no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. Because of the potential for serious adverse reactions in nursing infants from bupropion, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. 
Use in the Elderly: Bupropion has not been systematically evaluated in older patients. 
Adverse Reactions-Adverse events commonly encountered in patients treated with bupropion are agitation, dry mouth, insomnia, headache/migraine, nausea/vomiting, constipation, and tremor. 
Adverse events were sufficiently troublesome to cause discontinuation of treatment with bupropion in approximately ten percent of the 2400 patients and volunteers who participated in clinical trials during the product's initial development. The more common events causing discontinuation include neuropsychiatric disturbances (3.0%), primarily agitation and abnormalities in mental status; gastrointestinal disturbances (2.1%), primarily nausea and vomiting; neurological disturbances (1.7%), primarily seizures, headaches, and sleep disturbances; and dermatologic problems (1.4%), primarily rashes. It is important to note, however, that many of these events occurred at doses that exceed the recommended daily dose. 
Cardiovascular: Frequent was edema; infrequent were chest pain, EKG abnormalities, and shortness of breath/dyspnea; rare were flushing, pallor, phlebitis, and myocardial infarction.
Dermatologic: Frequent were nonspecific rashes; infrequent were alopecia and dry skin; rare were change in hair color, hirsutism, and acne.
Endocrine: Infrequent was gynecomastia; rare were glycosuria and hormone level change.
Gastrointestinal: Infrequent were dysphagia, thirst disturbance, and liver damage/jaundice; rare were rectal complaints, colitis, G.I. bleeding, intestinal perforation, and stomach ulcer.
Genitourinary: Frequent was nocturia; infrequent were vaginal irritation, testicular swelling, urinary tract infection, painful erection, and retarded ejaculation; rare were dysuria, enuresis, urinary incontinence, menopause, ovarian disorder, pelvic infection, cystitis, dysparenuia, and painful ejaculation. 
Musculoskeletal: Rare was musculoskeletal chest pain.
Physical/Psychological Dependence:
Controlled clinical studies conducted in normal volunteers, in subjects with a history of multiple drug abuse, and in depressed patients showed some increase in motor activity and agitation/excitement. 
In a population of individuals experienced with drugs of abuse, a single dose of 400 mg bupropion produced mild amphetamine-like activity as compared to placebo on the morphine-benzedrine subscale of the Addiction Research Center Index (ARCI) and a score intermediate between placebo and amphetamine on the Liking Scale of the ARCI. These scales measure general feelings of euphoria and drug desirability. 
Findings in clinical trials, however, are not known to predict the abuse potential of drugs reliably. Nonetheless, evidence from single-dose studies does suggest that the recommended daily dosage of bupropion when administered in divided doses is not likely to be especially reinforcing to amphetamine or stimulant abusers. However, higher doses, which could not be tested because of the risk of seizure, might be modestly attractive to those who abuse stimulant drugs. 
Overdose -Signs and Symptoms -There has been limited clinical experience with overdosage of bupropion. Thirteen overdoses occurred during clinical trials. Twelve patients ingested 850 to 4200 mg and recovered without significant sequelae. Another patient who ingested 9000 mg of bupropion and 300 mg of tranylcypromine experienced a grand mal seizure and recovered without further sequelae. 
Since introduction, overdoses of bupropion up to 17,500 mg have been reported. Seizure was reported in approximately one-third of all cases. Other serious reactions reported with overdoses of bupropion alone included hallucinations, loss of consciousness, and tachycardia. Fever, muscle rigidity, rhabdomyolysis, hypotension, stupor, coma, and respiratory failure have been reported when bupropion was part of multiple drug overdoses. 
Although most patients recovered without sequelae, deaths associated with overdoses of bupropion alone have been reported rarely in patients ingesting massive doses of bupropion. Multiple uncontrolled seizures, bradycardia, cardiac failure, and cardiac arrest prior to death were reported in these patients. 
Treatment
Following suspected overdose, hospitalization is advised. If the patient is conscious, vomiting should be induced by syrup of ipecac. Activated charcoal also may be administered every 6 hours during the first 12 hours after ingestion. Baseline laboratory values should be obtained. Electrocardiogram and EEG monitoring also are recommended for the next 48 hours. Adequate fluid intake should be provided. 
If the patient is stuporous, comatose, or convulsing, airway intubation is recommended prior to undertaking gastric lavage. Although there is little clinical experience with lavage following an overdose of bupropion, it is likely to be of benefit within the first 12 hours after ingestion since absorption of the drug may not yet be complete. 
Dosage-Several weeks (1-4) may pass before your condition improves. HOW TO USE THIS MEDICINE:  Follow the directions for using this medicine provided by your doctor. Space your doses evenly throughout the day.  Store this medicine at room temperature in a tightly-closed container, away from heat and light.  Continue to take this medicine even if you feel better.  Do not miss any doses. If you miss a dose of this medicine, take it as soon as you remember. Take the remaining doses for the day at evenly spaced intervals at least 4 hours apart. Do not take 2 doses at once.  Additional Information: Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children.  It is particularly important to administer bupropion in a manner most likely to minimize the risk of seizure (see WARNINGS). Increases in dose should not exceed 100 mg/day in a 3-day period. Gradual escalation in dosage is also important if agitation, motor restlessness, and insomnia, often seen during the initial days of treatment, are to be minimized. If necessary, these effects may be managed by temporary reduction of dose or the short-term administration of an intermediate to long-acting sedative hypnotic. A sedative hyponotic usually is not required beyond the first week of treatment. Insomnia may also be minimized by avoiding bedtime doses. If distressing, untoward effects supervene, dose escalation should be stopped. 
No single dose of bupropion should exceed 150 mg. Bupropion should be administered t.i.d., preferably with at least 6 hours between successive doses.  The usual adult dose is 300 mg/day, given t.i.d. Dosing should begin at 200 mg/day, given as 100 mg b.i.d. Based on clinical response, this dose may be increased to 300 mg/day, given as 100 mg t.i.d., no sooner than 3 days after beginning therapy
Increasing the Dosage Above 300 mg/Day: As with other antidepressants, the full antidepressant effect of bupropion may not be evident until 4 weeks of treatment or longer. An increase in dosage, up to a maximum of 450 mg/day, given in divided doses of not more than 150 mg each, may be considered for patients in whom no clinical improvement is noted after several weeks of treatment at 300 mg/day. Dosing above 300 mg/day may be accomplished using the 75 or 100 mg tablets. The 100 mg tablet must be administered q.i.d., with at least 4 hours between successive doses, in order not to exceed the limit of 150 mg in a single dose. Bupropion should be discontinued in patients who do not demonstrate an adequate response after an appropriate period of treatment at 450 mg/day. 
Elderly Patients: In general, older patients are known to metabolize drugs more slowly and to be more sensitive to the anticholinergic, sedative, and cardiovascular side effects of antidepressant drugs. Clinical trials enrolled several hundred patients 60 years of age and older. The experience with these patients and younger ones was similar. 
Maintenance: The lowest dose that maintains remission is recommended. Although it is not known how long the patient should remain on bupropion, it is generally recognized that acute episodes of depression require several months or longer of antidepressant drug treatment. 
IF YOU WILL BE USING THIS MEDICINE FOR AN EXTENDED PERIOD OF TIME, be sure to obtain necessary refills before your supply runs out. 
How Supplied Tablets are supplied for oral administration as 100-mg and 150-mg.

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