Applying neuropharmacology when treating patients with depression

Journal of Family Practice, Dec, 2003 by Adam Keller Ashton, Dale A. D'Mello, Bezalel Dantz, Jaye Hefner, F. George Leon, Gary A. Matson, C. Brendan Montano, James F. Pradko, Norman Sussman, Bertrand Winsberg

TABLE 1

Commonly prescribed antidepressants

COMPOUND
NAME            TRADE NAME       DRUG CLASS    STARTING DOSE

Bupropion       Wellbutrin       NDRI          100 mg 2 times daily
                Wellbutrin SR    NDRI          150 mg daily
                Wellbutrin XL    NDRI          150 mg daily
Citalopram      Celexa           SSRI          20 mg daily
Desipramine     Norpramin        TCA           50 mg daily
Escitalopram    Lexapro          SSRI          10 mg daily
Fluoxetine      Prozac           SSRI          20 mg daily
Fluvoxamine     Luvox            SSRI          50 mg daily
Mirtazapine     Remeron          SNRI          15 mg daily
                RemeronSolTab    SNRI          15 mg daily
Nefazodone      Serzone          SNRI          100 mg 2 times daily
Paroxetine      Paxil            SSRI          20 mg daily
                Paxil CR         SSRI          25 mg daily
Sertraline      Zoloft           SSRI          50 mg daily
Venlafaxine     Effexor          SNRI          75 mg daily
                Effexor XR       SNRI          75 mg daily

COMPOUND
NAME            TRADE NAME       INDICATED RANGE *

Bupropion       Wellbutrin       300 mg/d; up to 450 mg/d
                Wellbutrin SR    300 mg/d; up to 400 mg/d
                Wellbutrin XL    150 mg/d; up to 450 mg/d
Citalopram      Celexa           20-40 mg/d; up to 60 mg/d
Desipramine     Norpramin        150 mg/d; up to 250 mg/d
Escitalopram    Lexapro          10 mg/d; up to 20 mg/d
Fluoxetine      Prozac           20-40 mg/d; up to 80 mg/d
Fluvoxamine     Luvox            100 mg/d; up to 300 mg/d
Mirtazapine     Remeron          15-30 mg/d; up to 45 mg/d
                RemeronSoITab    15 mg/d; up to 45 mg/d
Nefazodone      Serzone          300 mg/d; up to 600 mg/d
Paroxetine      Paxil            20 mg/d; up to 50 mg/d
                Paxil CR         25 mg/d; up to 62.5 mg/d
Sertraline      Zoloft           50 mg/d; up to 200 mg/d
Venlafaxine     Effexor          75-150 mg/d; to up 225 mg/d
                Effexor XR       75 mg/d; up to 225 mg/d

* As indicated on specific prescribing information as of 1/15/03.

Source: Prescribing information for Wellbutrin, GIaxoSmithKline. 2002.
Prescribing information for Wellbutrin SR, GIaxoSmithKline. 2002.
Prescribing information for Celexa, Forest Pharmaceuticals, Inc. 2002.
Prescribing information for Norpramin, Aventis Pharmaceuticals. 2002.
Prescribing information for Lexapro, Forest Pharmaceuticals, Inc. 2002.
Prescribing information for Prozac, Eli Lilly and Company. 2002.
Prescribing information for Luvox, Solvay Pharmaceuticals, Inc. 2001.
Prescribing information for Remeron, Organon, Inc. 2002. Prescribing
information for RemeronSoITab, Organon, Inc. 2002. Prescribing
information for Serzone, Bristol-Meyers Squibb Company. 2002.
Prescribing information for Paxil, GIaxoSmithKline. 2002. Prescribing
information for Paxil CR, GIaxoSmithKline. 2002. Prescribing
information for Zoloft, Pfizer Inc. 2002. Prescribing information for
Effexor, Wyeth Laboratories. 2002. Prescribing information for Effexor
XR, Wyeth Laboratories. 2002.

TABLE 2

Summary of neurotransmitter actions
and potential desirable and undesirable effects

                                   Effects/side effects

Neurotransmitter        Positive                    Negative

                                         Acute            Chronic
                                         Occurs in        Lasting
                                         first 4 weeks    longer than
                                         of treatment     4 weeks
Serotonin           (A) Mood             Agitation        Poop-out
                    (B) Panic/phobia     Sweating         Apathy
                    (B) OCD              GI upset         Weight gain
                    (B) Rage             Slow tremor      Sexual
                                                            dysfunction
                    (B) PTSD, GAD        Sedation         Serotonin
                                                            syndrome
Norepinephrine      (A) Mood             Tremor           Hypertension
                    (B) Anxiety
                    (A) Vigilance
                    (B) Pain
Dopamine            (A) Mood             Insomnia         Psychosis
                    (B) Cravings         Agitation
                    (A) Concentration    Irritability
                    (B) Weight

                                        Medications

Neurotransmitter             NDRI                     SNRI

                     Wellbutrin                Effexor
                                               Remeron
                                               Serzone
Serotonin            [ILLUSTRATION OMITTED]    [up arrow]
Norepinephrine       [up arrow]                [up arrow]
Dopamine             [up arrow]                [ILLUSTRATION OMITTED]

                         Medications

Neurotransmitter             SSRI

                    Celexa
                    Lexapro
                    Luvox
                    Paxil
                    Prozac
                    Zoloft
Serotonin           [up arrow]
Norepinephrine      [ILLUSTRATION OMITTED]
Dopamine            [down arrow]

These are commonly accepted clinical correlates and not necessarily
indicative of cause and effect.

Source: J. Pradko
OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress
disorder; GAD, generalized anxiety disorder.

FIGURE 1

Dopamine/serotonin ratio

Bupropion    25.00
Desipramine   0.066
Nefazodone    0.058
Sertraline    0.013
Flouxetine    0.007
Venlafaxine   0.007
Fluvoxamine   0.001
Trazodone     0.001
Paroxetine    0.000

Adapted with permission from Richelson E. Pharmacology
of antidepressants--characteristics of the ideal drug. An
inventory for measuring depression. Mayo Clin Proc 1994;
69:1061-1081.

Note: Table made from bar graph.

FIGURE 2

Norepinephrine/serotonin ratio

Desipramine   379.10
Bupropion       6.719
Nefazodone      0.247
Venlafaxine     0.185
Fluoxetine      0.043
Trazodone       0.038
Paroxetine      0.022
Sertraline      0.016
Fluvoxamine     0.014

Adapted with permission from Richelson E. Pharmacology
of antidepressants--characteristics of the ideal drug. An
Inventory for measuring depression. Mayo Clin Proc 1994;
69:1061-1081.

Note: Table made from bar graph.