Psychopharmacology: A Comprehensive Guide to Mental Health Medications

Xanax is used short-term for anxiety. Common forms of Xanax tablets include 250 micrograms (mcg) or 500 (George & Tripp, 2023).

Adults: The usual dose of alprazolam for adults is 250 to 500 mcg given three times a day; however, up to 4 milligrams (mg) daily can be given if required.

Older adults: For older adults, the dose of Alprazolam is 250 mcg, given two to three times a day; however, it can be increased if necessary (George & Tripp, 2023).

Contraindications include respiratory depression. Caution should be used in patients with muscle weakness and organic brain changes.

Common side effects include decreased appetite, sexual dysfunction, impaired concentration, constipation, dermatitis, xerostomia, memory loss, movement disorders, and weight changes. Rare side effects include angioedema, gastrointestinal disorders, hepatic disorders, psychosis, suicidal thoughts, and abnormal thinking (George & Tripp, 2023).

Alprazolam is present in breast milk, and its use should be avoided if possible during breastfeeding.

Librium is indicated for short-term use for anxiety. Capsules come in 5 mg and 10 mg. Dosages are as follows:

Adults: The dose for adults is 10 mg, given three times a day. It can be increased if necessary, up to 60 to 100 mg daily in divided doses (Ahwazi et al., 2024).

Older adults: For the older population, the dose of chlordiazepoxide is 5 mg three times a day, which could be increased if required (Ahwazi et al., 2024).

Librium can be used in the treatment of alcohol withdrawal.

It is contraindicated in chronic psychosis and respiratory depression. Caution is advised with muscle weakness and organic brain changes (Ahwazi et al., 2024). Benzodiazepines are present in breast milk, and their use should be avoided if possible during breastfeeding (Ahwazi et al., 2024). With hepatic and renal impairment, dose adjustment is advised. Reduce to a maximum of 50% of the usual dose in mild to moderate impairment.

Common side effects include movement disorders. Less common side effects include abdominal distress, agranulocytosis, bone marrow disorders, erectile dysfunction, leukopenia, skin eruption, thrombocytopenia, urinary incontinence, and vertigo (Ahwazi et al., 2024).

Valium can be indicated for muscle spasms of varied etiology, sedation, alcohol withdrawal, and anxiety. Other uses include sedation in dental procedures, status epilepticus, febrile convulsions, and convulsions due to poisoning (Dhaliwal et al, 2023a). It is available as tablets, oral suspension, oral solution, and rectal tubes.

With anxiety in adults, valium is given by mouth. Adults can have 2-10 mg three times daily, increasing to 15–30 mg daily in divided doses if necessary. Older adults may be prescribed 1-2 mg three times a day, increasing if necessary to 7.5–15 mg daily (Dhaliwal et al., 2023a).

Valium can treat insomnia associated with anxiety. This is done by mouth, usually with 5–15 mg daily, to be taken at bedtime. Valium can also treat acute anxiety and agitation. It is usually given as an intramuscular injection or a slow intravenous injection. 10 mg is initially given, then 10 mg after four hours if needed.

Contraindications include respiratory depression, chronic psychosis, compromised airway, and hyperkinesis. Caution should be used with muscle weakness, organic brain changes, and central nervous system (CNS) depression. Parenteral administration should be closely monitored. There is a risk of neonatal withdrawal symptoms when valium is used during pregnancy, especially in the second half. Therefore, its use should be avoided unless required for seizure control. Also, valium is present in breast milk and should be avoided if possible during breastfeeding (Dhaliwal et al., 2023a).

Common side effects include appetite changes, gastrointestinal disturbances, movement disorders, palpitations, and vomiting. Less common side effects include bradycardia, bronchial secretion increase, cardiac arrest, gynecomastia, heart failure, memory loss, respiratory arrest, sexual dysfunction, and syncope (Dhaliwal et al., 2023a).

Specific administration directions include the following:

• Intravenous use: Emulsion formulation is preferred due to the reduced risk of venous thrombophlebitis.
• Oral administration: Can be used with or without food. 
• Rectal administration: Specific dosage forms are available for children and adults.

There are some special considerations. In children, Valium is used for seizures, muscle spasms, and anxiety, with specific doses based on age and condition. The dosage should be reduced in older adults, as they are more sensitive to CNS effects and risk of falls (Dhaliwal et al., 2023a).

Patient and carer advice includes the following:

• Warn patients about performing skilled tasks (e.g., driving) after using, as effects may last up to 24 hours.
• Patients should be aware of the risk of respiratory depression when receiving intravenous benzodiazepines.
• Advise to avoid alcohol or other CNS depressants while on diazepam therapy (Dhaliwal et al., 2023a).

Oxazepam can be used in the short term for anxiety. It is usually dosed in 10 mg and 15 mg tablets. For adults, the dose is 15-30 mg, given 3-4 times daily. For the older population, the dose is 10-20 mg, given 3-4 times daily (Singh & Abdijadid, 2023).

For insomnia associated with anxiety in adults, it is given as 15–25 mg once daily at bedtime, with a maximum dose of 50 mg (Singh & Abdijadid, 2023).

Oxazepam is contraindicated in chronic psychosis and respiratory depression. Caution should be used in cases of muscle weakness and organic brain changes.

Some patients may experience paradoxical effects such as increased hostility, aggression, talkativeness, excitement, or antisocial behavior. Dose adjustment may help attenuate these effects. Increased anxiety and perceptual disorders may also occur. Common side effects include fever, gastrointestinal disorders, leukopenia, memory loss, edema, psychosis, saliva alteration, speech slurring, suicidal ideation, syncope, urinary incontinence, urticaria, and vertigo (Singh & Abdijadid, 2023).

Oxazepam is present in breast milk, and its use should be avoided if possible during breastfeeding. Patients should be advised about potential side effects and the risk of paradoxical effects when taking oxazepam (Singh & Abdijadid, 2023).

Atomoxetine is usually prescribed for children aged 6–17 years. Sometimes, atomoxetine may be prescribed in adults.

For those having a body weight of up to 70 kg (Fedder et al., 2023):

• The initial dose is 500 mcg/kg and is given daily for seven days.
• The maintenance dose is 1.2 mg/kg daily.
• Doses may be given in a single dose or two divided doses, with the last dose no later than early evening.

For those having a body weight of above 70 kg (Fedder et al., 2023):

• The initial dose is 40 mg daily for seven days.
• The maintenance dose is 80 mg daily.

Contraindications include pheochromocytoma and severe cardiovascular or cerebrovascular disease. Atomoxetine should be used with caution in patients with aggressive behavior, mild to moderate cardiovascular and cerebrovascular disease, emotional lability, seizures, hostility, hypertension, mania, psychosis, QT interval prolongation, structural cardiac abnormalities, tachycardia, and a susceptibility to angle-closure glaucoma. In pregnancy, atomoxetine should be avoided unless the potential benefit outweighs the risks. With breastfeeding, avoid use, as the drug is present in milk in animal studies. With moderate hepatic impairment, half the dose should be used, and with severe impairment, the dose should be quartered (Fedder et al., 2023).

Common side effects include anxiety, decreased appetite, arrhythmias, asthenia, chills (in adults), constipation, depression, dizziness, drowsiness, dry mouth (in adults), jitteriness (in adults), gastrointestinal discomfort, headaches, hyperhidrosis (uncommon in children), menstrual irregularities (in adults), mood alterations, mydriasis (in children), nausea, palpitations, sexual dysfunction, sleep disorders, tremors (uncommon in children), urinary disorders (rare in children), vomiting, and weight loss. Less common side effects include behavioral changes, chest pain (though very common in children), dyspnea, feeling cold (in adults), hypersensitivity, muscle spasms (in adults), peripheral coldness (in adults), QT interval prolongation, suicidal behavior, syncope, tics (though very common in children), and blurred vision. Rare side effects include hallucinations, hepatic disorders, psychosis, Raynaud’s phenomenon, seizures, and sudden cardiac death (Fedder et al., 2023).

The patient should be monitored for the appearance or worsening of anxiety, depression, or tics. Record pulse, blood pressure, psychiatric symptoms, appetite, weight, and height at initiation of therapy, following dose adjustments, and every six months thereafter. Inform patients and caregivers about the risk and advise them to report any worsening of clinical symptoms, suicidal thoughts, or behaviors. Advise patients to recognize symptoms of hepatic issues, including abdominal pain, nausea, malaise, dark urine, or jaundice, and seek prompt medical attention if these occur (Fedder et al., 2023).

Methylphenidate is usually prescribed for children aged 6–17 years with ADHD.

For children 6–17 years (Verghese et al., 2024):

• The initial dose is 5 mg given once or twice daily.
• Increase by 5–10 mg daily if required, at weekly intervals.
• Maximum dose: 60 mg daily in 2–3 divided doses.
• The therapy should be stopped or switched if the patient shows no response. A bedtime dose may be necessary for rebound hyperactivity.

Sometimes, methylphenidate is prescribed in adults:

• The initial adult dose is 5 mg, and it is given two or three times daily.
• Increase according to response, up to 100 mg daily in 2–3 divided doses.
• A bedtime dose may be required if the effect wears off in the evening.

Contraindications include anorexia nervosa, arrhythmias, cardiomyopathy, cardiovascular disorders, heart failure, hyperthyroidism, mania, pheochromocytoma, psychosis, severe depression, severe hypertension, structural cardiac abnormalities, suicidal tendencies, uncontrolled bipolar disorder, and vasculitis. Caution should be used in agitation, alcohol dependence, anxiety, drug dependence, epilepsy (discontinue if seizures worsen), family history of Tourette syndrome, susceptibility to angle-closure glaucoma, and tics. With pregnancy, avoid methylphenidate use unless the potential benefit outweighs the risk. It should be avoided during breastfeeding, as limited data is available (Verghese et al., 2024).

Common side effects include aggression, alopecia, anxiety, decreased appetite, arrhythmias, arthralgia, abnormal behavior, cough, depression, diarrhea, dizziness, drowsiness, dry mouth, fever, gastrointestinal discomfort, growth restriction (in children), headaches, hypertension, laryngeal pain, altered mood, movement disorders, nasopharyngitis, nausea, palpitations, sleep disorders, vomiting, and weight loss. Less common side effects include chest discomfort, constipation, dyspnea, fatigue, hematuria, hallucinations, muscle complaints, psychotic disorders, suicidal behavior, tics, tremor, and vision disorders. Rare side effects include anemia, angina pectoris, cardiac arrest, cerebrovascular insufficiency, confusion, gynecomastia, hepatic coma, hyperfocus, hyperhidrosis, leukopenia, mydriasis, myocardial infarction, neuroleptic malignant syndrome, peripheral coldness, Raynaud’s phenomenon, seizures, sexual dysfunction, skin reactions, sudden cardiac death, thinking abnormal, and thrombocytopenia (Verghese et al., 2024).

The patient should be monitored for psychiatric disorders. Pulse, blood pressure, psychiatric symptoms, appetite, weight, and height should be recorded at initiation, following dose adjustments, and at least every six months thereafter. Abrupt withdrawal should be avoided (Verghese et al., 2024).

Different versions of modified-release preparations may not have the same clinical effect. Therefore, to avoid confusion, the healthcare providers should specify the brand to be dispensed. Advise patients that treatment may affect their ability to perform skilled tasks, particularly with sedative effects. Alcohol can increase these effects (Verghese et al., 2024).

Dextroamphetamine sulfate may be prescribed for refractory ADHD. Dextroamphetamine sulfate comes in the form of modified-release capsules, oral suspension, oral solution, and tablets. Modified-release formulations may vary in clinical effects. Always specify the brand to avoid confusion.

Common forms of the medication include the following (Shoar et al., 2023):

• Oral solution: 1 mg per 1 ml
• Tablets: 5 mg, 10 mg, 20 mg
• Modified-release capsules: 5 mg, 10 mg, 15 mg

For children 6–17 years: Initially 2.5 mg 2–3 times daily; increase by 5 mg weekly if required. Maintenance dose should be administered in 2–4 divided doses.

For adults: Initially 5 mg twice daily; increase weekly, up to a maximum of 60 mg daily, given in 2–4 divided doses (Shoar et al., 2023).

Contraindications include advanced arteriosclerosis, anorexia, life-threatening arrhythmias, cardiomyopathies, cardiovascular disorders, heart failure, history of alcohol or drug abuse, hyperexcitability, hyperthyroidism, moderate or severe hypertension, psychiatric disorders (including severe depression, schizophrenia, psychosis, bipolar disorder), and suicidal tendencies (Shoar et al., 2023).

Caution should be used in patients with a history of epilepsy (discontinue if seizures occur), mild hypertension, susceptibility to angle-closure glaucoma, tics and Tourette syndrome (discontinue use if tics occur), and growth restriction in children (monitor height and weight; drug-free periods may allow catch-up growth). Caution should also be used in patients with renal impairment. Dextroamphetamine sulfate should be avoided in pregnancy due to retrospective evidence of potential embryotoxicity. Because significant amounts of dextroamphetamine sulfate are excreted in milk, its use during breastfeeding should be avoided. Patients should be warned if treatment affects their ability to perform skilled tasks, such as driving, especially when alcohol is consumed. In all patients, avoid abrupt withdrawal (Shoar et al., 2023).

Common side effects include abdominal pain, anxiety, decreased appetite, arrhythmias, arthralgia, abnormal behavior, depression, dry mouth, headache, mood alterations, movement disorders, muscle cramps, nausea, palpitations, poor weight gain, sleep disorders, vertigo, vomiting, and weight loss (Shoar et al., 2023).

Growth should be monitored in children, and providers should be cautious of aggressive behavior or hostility. Pulse, blood pressure, psychiatric symptoms, appetite, weight, and height should be recorded when starting the therapy, after each dose adjustment, and at least every six months thereafter (Shoar et al., 2023).

Lisdexamfetamine is a prodrug of dexamfetamine. It is commonly prescribed for ADHD. Lisdexamfetamine dimesylate comes in the form of capsules: 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, and 70 mg.

For children 6–17 years (Medsafe, 2024):

• Initially, 30 mg once daily (alternative: 20 mg once daily) is increased by 10–20 mg weekly if needed.
• Maximum dose is 70 mg per day.
• Discontinue if the response is insufficient.

For adults (Medsafe, 2024):

• Initially, 30 mg is taken once daily, and then increased by 20 mg weekly if necessary.
• Maximum dose is 70 mg per day.
• Discontinue if response is insufficient.

Contraindications include advanced arteriosclerosis, agitated states, hyperthyroidism, moderate to severe hypertension, and symptomatic cardiovascular disease. Cautions include bipolar disorder, history of cardiovascular disease, history of substance abuse, seizures (may lower seizure threshold; discontinue if seizures occur), psychotic disorders, a susceptibility to angle-closure glaucoma, tics, and Tourette syndrome. With pregnancy, use lisdexamfetamine only if the potential benefit is more than the risk. Lisdexamfetamine should be avoided in breastfeeding, as it is present in breast milk. For severe renal impairment, the maximum dose is 50 mg daily (Medsafe, 2024).

Common side effects include abdominal pain (upper), anxiety, decreased appetite, abnormal behavior, constipation or diarrhea, dizziness, dry mouth, dyspnea, fatigue, feeling jittery, headache, hyperhidrosis (uncommon in children), insomnia, mood alterations, movement disorders (uncommon in children), nausea, palpitations, sexual dysfunction, tachycardia, tremors, and weight loss. Uncommon side effects include depression in adults, drowsiness in adults, fever in adults, logorrhea, psychiatric disorders in adults, skin reactions in adults, taste alteration, blurred vision, and vomiting (very common in children). Rare side effects include angioedema, cardiomyopathy, hallucinations, hepatitis (allergic), mydriasis, psychotic disorders, Raynaud’s phenomenon, seizures, and Stevens-Johnson syndrome (Medsafe, 2024).

It is important to note the symptoms of overdose, which may include wakefulness, excessive activity, paranoia, hallucinations, and hypertension, followed by exhaustion, convulsions, hyperthermia, and coma (Medsafe, 2024).

The patient should be monitored for aggressive behavior or hostility during initial treatment. Monitor pulse, blood pressure, and psychiatric symptoms before treatment, after dose adjustments, and every six months. In adults, monitor weight; in children, monitor height, weight, and appetite every six months. Inform patients that their driving abilities may be affected, especially with sedative effects that can be increased by alcohol. Abrupt withdrawal should be avoided (Medsafe, 2024).

Patients should be instructed to swallow capsules whole or mix contents with soft food (e.g., yogurt) or a glass of water/juice. Ensure contents are fully dispersed and consumed immediately.

Valproic acid is indicated for migraine prophylaxis, epilepsy, and manic episodes in bipolar disorder.

Valproic acid comes in the form of an oral suspension and gastro-resistant capsules:

• Convulex: 150 mg, 300 mg, 500 mg
• Syonell: 250 mg, 500 mg
• Depakote: 250 mg, 500 mg
• Belvo: 250 mg, 500 mg 

Dosing for bipolar disorder is as follows (Rahman et al., 2024):

• Manic episodes in bipolar disorder:
  • Adult: Initially, the dose is 750 mg daily (2-3 doses), and it is increased as needed. The maximum dose is 45 mg/kg daily with careful monitoring.

Valproic acid carries some risks. It is contraindicated in women of childbearing potential due to teratogenic risks. There is a risk of suicide due to the increased risk of suicidal thoughts and behavior. Caution is advised when switching between manufacturers (Rahman et al., 2024).

Contraindications include acute porphyria, mitochondrial disorders, severe hepatic dysfunction, and urea cycle disorders. Caution should be used with liver dysfunction, systemic lupus erythematosus, children under three years old, and metabolic disorders. With breastfeeding, valproic acid should be avoided due to its presence in milk and the potential harm to infants. Valproic acid is also contraindicated in pregnancy, unless the patient has epilepsy and no alternative is available.

Side effects include the following (Rahman et al., 2024):

• Common: Abdominal pain, alopecia, confusion, drowsiness, nausea, and weight gain.
• Rare: Anemia, angina, hepatic disorders, pancreatitis, and psychosis.
• Serious: Liver toxicity, suicidal behavior, and severe skin reactions.

Liver function and blood count should be monitored, especially during the first six months. Close monitoring for liver toxicity, bleeding risks, and weight changes may be necessary (Rahman et al., 2024).

Importantly, for treatment cessation, gradually reduce the dose over at least four weeks, especially in bipolar disorder. For prescribing and dispensing, ensure women use effective contraception with the ongoing valproate therapy. Consistent brand or generic valproic acid products are recommended for epilepsy treatment. The patient should inform their provider about liver or blood disorder symptoms and pancreatitis. Patients should not stop without consulting their primary care provider (Rahman et al., 2024).

Asenapine is used in the treatment of moderate to severe manic episodes in bipolar disorder (monotherapy or combination therapy).

The adult dose is 5 mg twice daily, which may be increased to 10 mg twice daily based on response (Chwieduk & Scott, 2011).

It should be used with caution in dementia with Lewy bodies. In pregnancy, use only if the potential benefit outweighs the risk. With breastfeeding, asenapine should be avoided due to its presence in breast milk. Caution should be used in moderate hepatic impairment and avoided in severe impairment. With renal impairment, asenapine should be used with caution if creatinine clearance is < 15 ml/min (Chwieduk & Scott, 2011).

Side effects include the following:

• Common: Anxiety, increased appetite, nausea, oral disorders, and altered taste.
• Uncommon: Dysarthria, dysphagia, sexual dysfunction, and syncope.

Asenapine is available as Sycrest in 5 mg and 10 mg sublingual tablets. Sublingual tablets should be placed under the tongue. The patient should be asked not to eat or drink for ten minutes (Chwieduk & Scott, 2011).

Lithium salts are indicated in the long-term management of bipolar disorder to prevent the recurrence of manic episodes (Chokhawala et al., 2024).

Contraindications include Addison’s disease, cardiac disorders, untreated hypothyroidism, and low-sodium diets. Caution should be used in older adults, those with epilepsy, myasthenia gravis, psoriasis, and QT interval prolongation. Due to teratogenicity risks, lithium salts should be avoided in pregnancy, especially in the first trimester. Because lithium salts are present in breast milk, breastfeeding should be avoided. Exercise caution should be used if the patient has mild-to-moderate renal impairment (Chokhawala et al., 2024).

It is important that abrupt withdrawal is avoided. The provider should monitor thyroid function and renal and cardiac health. Regular serum lithium concentrations should be monitored.

Side effects include the following:

• Common: Abdominal discomfort, memory loss, polyuria, tremor, and hypothyroidism.
• Rare: Nephropathy, nephritis, arrhythmia, weight changes, and vision disorders.
• Severe: Rhabdomyolysis, cardiac arrest, and kidney failure.

For treatment cessation, gradually reduce the dose over 4-12 weeks to minimize relapse risk.

Patients should report lithium toxicity, signs of hypothyroidism, renal dysfunction, or intracranial hypertension. They should also maintain adequate fluid intake and avoid sodium changes (Chokhawala et al., 2024).

Lithium carbonate

Lithium carbonate is indicated in the treatment and prophylaxis of mania, bipolar disorder, recurrent depression, and aggressive or self-harming behavior (Chokhawala et al., 2024).

Lithium carbonates often come in the form of (Chokhawala et al., 2024):

• Camcolit (400 mg)
• Liskonum (450 mg)
• Priadel (200 mg, 400 mg)

Dosages include the following (Chokhawala et al., 2024):

• Adults:
  • Initially, 1–1.5 grams (g) daily (divided doses) is given, adjusted according to serum lithium concentration.
  • Once stabilized, switch to once-daily administration.
• Older adults:
  • Reduce the initial dose and adjust it according to serum lithium concentrations.
  • Once stabilized, it is preferred to do once-daily administration.

Prophylaxis:

• Adult:
  • 300–400 mg daily with the dose adjusted according to serum lithium concentration.
  • Once stabilized, it is preferred to do once-daily administration.

It may be necessary to start with 200–400 mg daily for adults weighing up to 50 kg (Chokhawala et al., 2024).

Serum lithium levels should be monitored regularly (weekly after initiation, then every 3-6 months).

Side effects include possible nephropathy, hypothyroidism, weight changes, and tremors.

Due to teratogenicity risks, lithium carbonate should be avoided in pregnancy, especially during the first trimester. It should also be avoided in breastfeeding, due to the toxicity risk for the infant.

Caution should be used with mild to moderate renal impairment and avoided in severe cases of renal impairment.

To prevent relapse, the dose should be gradually reduced during treatment cessation (Chokhawala et al., 2024).

Lithium citrate

Lithium citrate is indicated for the treatment and prophylaxis of mania, bipolar disorder, recurrent depression, and aggressive or self-harming behavior (Chokhawala et al., 2024).

Lithium citrate comes in the following forms (Chokhawala et al., 2024):

• Li-Liquid®
  • Lithium citrate 509 mg per 5 ml, 1.018 g per 5 ml.
  • 150 ml bottle.
  • For dose equivalence, 509 mg lithium citrate = 200 mg lithium carbonate.
• Priadel® Liquid:
  • Lithium citrate 520 mg per 5 ml, 150 ml bottle.
  • For dose equivalence, 520 mg lithium citrate = 204 mg lithium carbonate.

Dosage recommendations are as follows:

• Adult:
  • Initial doses are divided throughout the day, switching to once-daily administration when serum lithium concentration stabilizes.

Body-weight adjustments are as follows (Chokhawala et al., 2024):

• Up to 50 kg:
  • Start with 509 mg daily (divided doses).
• Above 50 kg:
  • Start with 1.018–3.054 g daily (divided doses).
• Older adults:
  • Initially, 509 mg should be taken daily in two divided doses, with doses being adjusted according to serum lithium concentration.

A common side effect of lithium citrate is polydipsia (excessive thirst).

Serum lithium concentrations should be monitored regularly for effectiveness and toxicity.

Caution should be used in patients with renal impairment.

This medication is unsuitable for abrupt withdrawal; gradual reduction is advised (Chokhawala et al., 2024).

Isocarboxazid is prescribed for depression. Isocarboxazid comes as 10 mg tablets. Dosing is as follows (Multum, 2024):

Adults:

• Start with 30 mg daily (single or divided doses).
• Under close supervision, it can be increased to 60 mg daily after four weeks.
• Reduce to 10-20 mg daily as maintenance, up to 40 mg if needed.

Older adults:

• Start with 5–10 mg daily.

Side effects may include granulocytopenia, peripheral edema, and sexual dysfunction.

Isocarboxazid should not be used while breastfeeding. Caution should be used in patients with renal Impairment (Multum, 2024).

Phenelzine is an older MAOI used (less commonly) to treat depression.

Adults (Sidhu & Marwaha, 2023):

• Start with 15 mg three times a day.
• Increase to 15 mg four times a day if necessary, up to 30 mg three times daily for hospital patients.
• It may take up to four weeks for a response.
• Once effective, gradually reduce to the lowest maintenance dose (15 mg on alternate days may suffice).

Side effects may include cardiovascular insufficiency, delirium, electrolyte imbalance, fatal progressive hepatocellular necrosis, jitteriness, fever, gastrointestinal disorder, glaucoma, hypertensive crisis, impaired driving ability, intracranial hemorrhage, lupus-like syndrome, malaise, mood changes, movement disorders, increased muscle tone, neuroleptic malignant syndrome, nystagmus, edema, respiratory disorders, seizures, shock-like coma, and repetitive speech (Sidhu & Marwaha, 2023).

Avoid use during breastfeeding as there is limited information available on the effects.

Tranylcypromine is another MAOI used for depression. It typically comes in 10 mg tablets (Parikh et al., 2025).

Adults (Parikh et al., 2025):

• Start with 10 mg twice daily (take before 3 p.m. to avoid sleep disturbances).
• Increase if necessary after one week, up to 30 mg daily in divided doses (10 mg in the morning, 20 mg in the afternoon).
• Maintain with 10 mg daily, up to 30 mg under close supervision.

Contraindications include a history of hepatic disease and hyperthyroidism.

Common side effects include chest pain, diarrhea, drug dependence, extrasystole, flushing, hypertension, hypomania, mydriasis, pain, pallor, photophobia, sleep disorders, and a throbbing headache (Parikh et al., 2025).

Regarding breastfeeding, tranylcypromine is present in milk according to the animal studies; therefore, its use should be avoided during breastfeeding.

Citalopram can be prescribed for depressive disorders. Tablets come in the form of 10, 20, and 40 mg. Oral drops come in 40 mg per ml (Sharbaf Shoar et al., 2023).

By mouth (tablets):

• Adults: 20 mg daily, increase to 40 mg if needed (increases at three or four week intervals).
• Older adults: 10–20 mg daily.

By mouth (oral drops):

• Adults: 16 mg daily, increase to 32 mg if needed.
• Older Adults: 8–16 mg daily.

Citalopram can also be used to treat panic disorder.

By mouth (tablets):

• Adults: Start with 10 mg daily, increase to 20–30 mg as required (maximum is 40 mg).
• Older adults: 10 mg daily (maximum is 20 mg).

By mouth (oral drops):

• Adults: Start with 8 mg daily, increase to 16–24 mg (maximum 32 mg).
• Older adults: 8 mg daily (maximum is 16 mg).

Oral drops should be mixed with water, orange juice, or apple juice before taking (Sharbaf Shoar et al., 2023).

Contraindications include QT-interval prolongation. Caution should be used in patients who are susceptible to QT-interval prolongation and renal impairment. Research has shown that citalopram has been found in breast milk; breastfeeding should be avoided or performed with caution.

Common side effects include acute angle-closure glaucoma, apathy, flatulence, hypersalivation, migraine, and rhinitis. Rare side effects include cough and tonic-clonic seizures (Sharbaf Shoar et al., 2023).

When patients have mild to moderate hepatic impairment, the following guidelines should be followed (Sharbaf Shoar et al., 2023):

• Tablets: Initially, 10 mg daily should be prescribed. The maximum is 20 mg daily.
• Oral drops: Initially, 8 mg daily should be prescribed. The maximum is 16 mg daily.

For treatment cessation, gradually reduce the dose over four weeks or longer if withdrawal symptoms appear.

The patient should be counseled on oral drop administration and the effects on driving and skilled tasks.

Escitalopram is an active enantiomer of citalopram. It is indicated for depressive illness, GAD, OCD, panic disorder, and social anxiety disorder (Landy et al., 2023).

Medicinal forms (Landy et al., 2023):

• Tablets: 5, 10, and 20 mg
• Oral drops: 20 mg per ml

Dosing is as follows (Landy et al., 2023):

• Adults: Start with 10 mg daily, increase to 20 mg daily.
• Older adults: Start with 5 mg daily. The maximum is 10 mg daily.
• For panic disorder: Start with 5 mg daily for seven days, then increase to 10 mg daily. The maximum is 20 mg daily.
• For social anxiety disorder: Start with 10 mg daily, then increase after 2–4 weeks. The usual dose is 5–20 mg daily.

Contraindications include QT-interval prolongation. A common side effect is sinusitis. Because escitalopram is present in breast milk, this medication should be avoided while breastfeeding (Landy et al., 2023).

For patients with hepatic Impairment, dosing modifications may be needed. Start with 5 mg daily for two weeks for mild to moderate impairment, then increase to 10 mg. With severe impairment, use with caution and titrate carefully. Use caution for patients with renal impairment if creatinine clearance is less than 30 ml/min (Landy et al., 2023).

For treatment cessation, gradually reduce the dose over four weeks, or longer if withdrawal symptoms appear.

The patient should be counseled on oral drop administration and the effects on driving and skilled tasks.

Fluoxetine is indicated to treat a variety of disorders, including major depression, bulimia, OCD, and menopausal symptoms.

Medicinal forms (Sohel et al., 2024):

• Tablets: 10, 20, 30, and 40 mg
• Oral solution: 20 mg/5 ml
• Dispersible tablets: 20 mg
• Capsules: 10, 20, 30, and 40 mg 

For major depression (Sohel et al., 2024):

• Adults: Start with 20 mg daily, then increase after 3-4 weeks if needed. The maximum is 60 mg.
• Older adults: Start with 20 mg daily. The maximum dose is 40-60 mg if required.

For OCD (Sohel et al., 2024):

• Adults: Start with 20 mg daily, then increase up to 60 mg daily.
• Older adults: Start with 20 mg, then increase to the maximum of 60 mg if needed.

Fluoxetine has a long half-life, which should be considered when adjusting doses. Common side effects include chills, abnormal feelings, postmenopausal hemorrhage, uterine disorder, and blurred vision. Less common side effects include cold sweats, dysphagia, hypotension, and mood changes. More rare side effects include buccoglossal syndrome, leukopenia, neutropenia, and respiratory disorders (Sohel et al., 2024).

Fluoxetine is present in breast milk; therefore, it should be avoided during breastfeeding.

For patients with hepatic impairment, dose reduction or an increased dose interval is recommended.

Dispersible tablets can be dissolved in water or swallowed whole (Sohel et al., 2024).

Patients should be cautioned about the potential effects on driving and skilled tasks.

Fluvoxamine is indicated for depressive disorders and OCD.

Medicinal forms (Medscape, n.d.):

• Tablets: 50 mg, 100 mg
• An oral solution can be made if needed.

For depressive illness:

• Adults: 50–100 mg daily, then increase to 300 mg if needed. The maximum is 300 mg. Doses are often divided if they are over 150 mg.

For OCD:

• Adults: Start with 50 mg daily, then increase to 300 mg as needed.

Start with a low dose for patients with hepatic and renal impairment.

Maintenance doses are usually 100 mg daily, up to 300 mg daily in divided doses (Medscape, n.d.).

Common side effects include gastrointestinal upset, headache, and sleep-related difficulties. More rare side effects include hepatic dysfunction, glaucoma, and neuroleptic malignant syndrome.

Because fluvoxamine is present in breast milk, it should be avoided during breastfeeding.

For treatment cessation, a gradual reduction over four weeks is recommended. It may be necessary to have a longer reduction period for long-term treatment.

Patients should be counseled on the effects of driving and skilled tasks. 

Paroxetine is indicated for major depression, social anxiety disorder, PTSD, and GAD.

Medicinal forms (Shrestha et al., 2023):

• Oral suspension: Seroxat 20mg/10ml liquid, sugar-free, 150 ml
• Tablet: 10 and 20 mg tablets 

Dosing for depression is as follows (Shrestha et al., 2023):

• Adults: 20 mg daily, then increased to a maximum of 50 mg daily if needed.
• Older adults: 20 mg daily, with a maximum of 40 mg daily.

Dosing for OCD includes the following (Shrestha et al., 2023):

• Adults: Initially 20 mg daily, increased gradually to a maximum of 60 mg daily.
• Older adults: Initially 20 mg daily, increased gradually to a maximum of 40 mg daily.

Dosing for panic disorder may look like the following (Shrestha et al., 2023):

• Adults: Initially 10 mg daily, increased gradually to a maximum of 60 mg daily.
• Older adults: Initially 10 mg daily, increased gradually to a maximum of 40 mg daily.

Caution should be taken with achlorhydria and high gastric pH (reduces absorption of oral suspension). Taking paroxetine during pregnancy may increase the risk of congenital malformations, especially in the first trimester. Dose adjustments are recommended for patients with hepatic impairment; a lower dose may be necessary. It should also be used with caution in patients with renal impairment if the creatinine clearance is < 30 ml/min (Shrestha et al., 2023).

Common side effects include blurred vision. Less common side effects include impaired diabetic control, acute glaucoma, hepatic disorders, and peripheral edema.

For treatment cessation, the dose should be tapered gradually to avoid withdrawal symptoms. Patients should be counseled on potential effects on driving and skilled tasks (Shrestha et al., 2023). 

Sertraline has indications for depression, OCD, panic disorder, PTSD, and social anxiety disorder.

Sertraline comes in tablets, such as 25 mg, 50 mg, and 100 mg (Singh & Saadabadi, 2023).

For depression and OCD, adults should initially be prescribed 50 mg daily, increased in steps of 50 mg weekly, with a maximum of 200 mg daily.

For panic disorder, PTSD, and social anxiety disorder, adults should initially be prescribed 25 mg daily for one week, increased to 50 mg daily, with a maximum of up to 200 mg daily (Singh & Saadabadi, 2023).

Common side effects include chest pain, depression, and gastrointestinal disorders. Less common effects include back pain, chills, cold sweats, dysphagia, hypertension, and muscle complaints, and rare side effects include cardiac disorders, coma, diabetes mellitus, and drug dependence (Singh & Saadabadi, 2023).

Patients and providers should consider the risks associated with pregnancy and breastfeeding. With severe hepatic impairment, sertraline should be avoided. Dose reduction or interval adjustment may be necessary in mild to moderate impairment (Singh & Saadabadi, 2023).

Duloxetine inhibits the reuptake of serotonin and norepinephrine. It is indicated for major depression, GAD, and stress urinary incontinence.

Medicinal forms (Dhaliwal et al., 2023b):

• Gastro-resistant capsules: Duloxetine 20 mg, 30 mg, 40 mg, 60 mg, 90 mg, and 120 mg
• Cymbalta: 30 mg, 60 mg
• Depalta: 30 mg, 60 mg
• Duciltia: 30 mg, 60 mg

For major depressive disorder, adults are generally prescribed 60 mg once daily.

For GAD, adults are initially prescribed 30 mg once daily, which is then increased to 60 mg once daily if necessary; the maximum dose is 120 mg/day (Dhaliwal et al., 2023b).

Cautions include bleeding disorders, cardiac disease, a history of mania, a history of seizures, hypertension, and a risk of angle-closure glaucoma (Dhaliwal et al., 2023b).

Common side effects include anxiety, decreased appetite, constipation, diarrhea, dizziness, drowsiness, dry mouth, fatigue, flushing, headache, muscle complaints, nausea, palpitations, sexual dysfunction, sleep disorders, tremors, urinary disorders, vomiting, and weight changes. Less common side effects include apathy, arrhythmias, abnormal behavior, chills, disorientation, dysphagia, ear pain, gait abnormality, hyperglycemia, postural hypotension, and suicidal behaviors. More rare side effects include angioedema, cutaneous vasculitis, dehydration, galactorrhea, hallucination, hyperprolactinemia, hypertensive crisis, hyponatremia, hypothyroidism, serotonin syndrome, and Stevens-Johnson syndrome (Dhaliwal et al., 2023b).

Duloxetine should be avoided in patients with stress urinary incontinence and hepatic impairment. It should also be avoided in patients with renal impairment if the creatinine clearance is < 30 ml/min. It also poses a risk of neonatal withdrawal syndrome if given near term. Duloxetine is present in breast milk; therefore, use should be avoided during breastfeeding (Dhaliwal et al., 2023b).

Treatment cessation may cause nausea, vomiting, headache, anxiety, dizziness, paresthesia, sleep disturbances, and tremors. The dose should be gradually reduced over at least 1-2 weeks (Dhaliwal et al., 2023b).

Venlafaxine is an SNRI. It is indicated for major depression, GAD, social anxiety disorder, and panic disorder.

Medicinal forms (Singh & Saadabadi, 2024):

• Modified-release tablets: 75 mg, 150 mg
• Modified-release capsules: 75 mg, 150 mg
• Oral solution: 37.5 mg/5 ml, 75 mg/5 ml 

Dosing is as follows (Singh & Saadabadi, 2024):

For major depression:

• Immediate release: 75 mg daily in two divided doses, increased to 375 mg/day if necessary.
• Modified release: 75 mg once daily, increased to 375 mg/day if necessary.

For GAD:

• Modified release: 75 mg once daily, increased to 225 mg/day if necessary.

For social anxiety disorder:

• Modified release: 75 mg once daily, increased to 225 mg/day if necessary.

For panic disorder:

• Modified release: Start with 37.5 mg once daily for seven days, then increase to 75 mg/day, up to 225 mg/day.

Contraindications include uncontrolled hypertension, due to its noradrenaline reuptake inhibition, which can lead to an increase in blood pressure. Cautions include conditions associated with a high risk of cardiac arrhythmia, diabetes, heart disease, bleeding disorders, epilepsy, a history or family history of mania, and a susceptibility to angle-closure glaucoma. There is a postpartum hemorrhage risk when used in the month before delivery due to its effect on platelet function. With pregnancy, avoid unless the potential benefit outweighs the risk due to toxicity in animal studies. There is a risk of withdrawal effects in neonates. Venlafaxine is also present in breast milk; it should be avoided during breastfeeding (Singh & Saadabadi, 2024).

For patients with hepatic impairment, exercise caution with inter-individual variability in clearance. Consider dose reduction in mild to moderate impairment and more than a 50% reduction in severe impairment. With renal impairment, use with caution. If eGFR < 30 ml/min, consider halving the usual dose.

Common side effects include anxiety, decreased appetite, arrhythmias, chills, confusion, constipation, diarrhea, dizziness, dry mouth, headache, hypertension, menstrual irregularities, nausea, palpitations, sexual dysfunction, sleep disorders, tremor, urinary disorders, vomiting, and weight changes. Less common side effects include alopecia, apathy, abnormal behavior, derealization, hemorrhage, hallucination, hypotension, mood changes, photosensitivity reaction, and syncope. Rare side effects include agranulocytosis, angle-closure glaucoma, bone marrow disorders, delirium, hepatitis, hyponatremia, neuroleptic malignant syndrome, pancreatitis, QT interval prolongation, seizure, serotonin syndrome, and severe cutaneous adverse reactions (SCARs) (Singh & Saadabadi, 2024).

With treatment cessation, there is a higher risk of withdrawal effects (e.g., gastrointestinal disturbances, headache, dizziness). Gradually reduce the dose over at least 1-2 weeks (Singh & Saadabadi, 2024).

Amitriptyline hydrochloride is used to treat depression, as well as other conditions such as abdominal pain or discomfort for those who have not responded to other therapies, migraine prophylaxis, neuropathic pain, and emotional lability in multiple sclerosis.

Medicinal forms (Thour & Marwaha, 2023):

• Oral solution: Available in 10 mg/5 ml, 25 mg/5 ml, and 50 mg/5 ml formulations.
• Tablet: Available in 10 mg, 25 mg, and 50 mg tablets.

For major depressive disorder (Thour & Marwaha, 2023):

• Adults: Initially, 50 mg daily in two divided doses is increased in steps of 25 mg, and the maximum dose that could be given in a day is 150 mg daily in two divided doses.
• Older Adults: The initial dose in the older population is 10 to 25 mg daily, increased up to 100–150 mg daily in two divided doses if necessary.

Contraindications include arrhythmias, mania, heart block, and the immediate recovery period after myocardial infarction. Caution should be used with cardiovascular disease, constipation, diabetes, epilepsy, history of bipolar disorder, psychosis, hyperthyroidism, increased intraocular pressure, significant suicide risk, pheochromocytoma, prostatic hypertrophy, pyloric stenosis, susceptibility to angle-closure glaucoma, and urinary retention. Treatment should be stopped if the patient enters a manic phase. Older adults are particularly susceptible to side effects and should be monitored closely (Thour & Marwaha, 2023).

Common side effects include anticholinergic syndrome, drowsiness, and QT interval prolongation. With pregnancy, use only if the potential benefit outweighs the risk. In patients with mild to moderate hepatic impairment, use caution and avoid use in severe impairment (Thour & Marwaha, 2023).

It is important to note that withdrawal effects may occur within five days of stopping treatment. Symptoms are usually mild and self-limiting, but may be severe. The risk increases if the antidepressant is stopped suddenly after prolonged use. The dose should be gradually tapered over about four weeks (Thour & Marwaha, 2023).

Limited quantities of TCAs should be prescribed at any one time because of the dangerous cardiovascular and epileptogenic effects in higher dosages. Providers should educate patients on drowsiness and how it may affect the performance of skilled tasks (e.g., driving). It is important to note that alcohol may enhance side effects (Thour & Marwaha, 2023).

Clomipramine hydrochloride is indicated for depression, phobic and obsessional states, and other conditions, such as cataplexy associated with narcolepsy.

Medicinal forms (Wilson & Tripp, 2024):

• Capsules: Available in 10 mg, 25 mg, and 50 mg formulations.
• Oral suspensions are also available.

For depression (Wilson & Tripp, 2024):

• Adults: Initially, 10 mg daily is given, and if necessary, it is increased to 30–150 mg daily in divided doses. The dose is increased gradually. Alternatively, 30–150 mg may be prescribed once daily, taken at bedtime. The maximum is 250 mg daily.
• Older adults: Initially, 10 mg daily is prescribed, which can be increased to 30–75 mg daily. The dose may be increased carefully over approximately 10 days.

For phobic and obsessional states (Wilson & Tripp, 2024):

• Adults: Initially 25 mg daily, increased to 100–150 mg daily. The dose is increased gradually over two weeks. The maximum dose is 250 mg daily.
• Older adults: The initial dose for the older population is 10 mg daily, which can be increased to 100 to 150 mg daily. The dose is increased gradually over two weeks. The maximum dose for older adults is 250 mg daily.

Clomipramine hydrochloride is contraindicated in acute porphyria, arrhythmias, mania, heart block, and in the immediate recovery period after myocardial infarction. Caution should be used with cardiovascular disease, constipation, epilepsy, bipolar disorder, history of psychosis, hyperthyroidism, increased intraocular pressure, patients with a significant risk of suicide, pheochromocytoma, prostatic hypertrophy, a susceptibility to angle-closure glaucoma, urinary retention, and risk factors for QT interval prolongation (correct hypokalemia before initiating treatment). Neonatal withdrawal symptoms have been reported if used during the third trimester. Providers should exercise caution when using in patients with hepatic impairment (Wilson & Tripp, 2024).

Common side effects include aggression, anxiety, arrhythmias, breast enlargement, impaired concentration, confusion, constipation, delirium, depersonalization, exacerbated depression, diarrhea, dizziness, drowsiness, dry mouth, fatigue, galactorrhea, gastrointestinal disorders, hallucination, headache, hot flashes, hyperhidrosis, hypotension, memory loss, altered mood, movement disorders, altered muscle tone, muscle weakness, mydriasis, nausea, palpitations, paresthesia, photosensitivity reactions, sexual dysfunction, skin reactions, sleep disorders, speech disorders, altered taste, tinnitus, tremors, urinary disorders, vision disorders, vomiting, weight gain, and yawning. Less common side effects include psychosis and seizures, and rare side effects include agranulocytosis, alopecia, cardiac conduction disorders, eosinophilia, glaucoma, hepatic disorders, hyperpyrexia, leukopenia, neuroleptic malignant syndrome, edema, QT interval prolongation, respiratory disorders, thrombocytopenia, and vaginal hemorrhage (Wilson & Tripp, 2024).

Cardiac and hepatic function should be monitored during long-term use. It is important to note that withdrawal effects may occur within five days of stopping treatment. The effects range from mild to severe. The medication should be tapered carefully (Wilson & Tripp, 2024).

Providers should educate patients about the effects of drowsiness.

Doxepin is another TCA used for depressive illness, particularly where sedation is required.

Medicinal forms (Almasi et al., 2024):

• Capsules: Doxepin 25 mg, 50 mg
• Oral Suspension: Available by special-order manufacturers
  • Adults: Initially, 75 mg is taken daily in divided doses; alternatively, 75 mg is taken once daily at bedtime. The dose should be adjusted according to the response. The maintenance dose is 25–300 mg daily, with doses above 100 mg being prescribed in three divided doses.
  • Older adults: In older adults, lower doses should be initiated and then titrated according to response.

Contraindications include acute porphyria and during the manic phase of bipolar disorder. Cautions include cardiovascular disease, constipation, epilepsy, bipolar disorder, history of psychosis, hyperthyroidism, increased intraocular pressure, a susceptibility to angle-closure glaucoma, patients with a significant suicide risk and history, pheochromocytoma, prostatic hypertrophy, hepatic and renal impairment, and urinary retention. Doxepin should be used cautiously in pregnant women. For breastfeeding, the amount secreted into breast milk is believed to be too small to be harmful. However, accumulation of metabolites may cause sedation and respiratory depression in neonates (Almasi et al., 2024).

Common side effects include agitation, agranulocytosis, alopecia, anticholinergic syndrome, decreased appetite, asthenia, asthma exacerbations, bone marrow depression, breast enlargement, cardiovascular effects, chills, confusion, constipation, diarrhea, dizziness, drowsiness, dry mouth, dyspepsia, eosinophilia, face edema, flushing, galactorrhea, gynecomastia, hemolytic anemia, hallucinations, headache, hyperhidrosis, hyperpyrexia, increased risk of fracture, jaundice, leukopenia, mania, movement disorders, nausea, oral ulceration, paranoid delusions, photosensitivity reaction, postural hypotension, psychosis, seizures, abnormal sensations, sexual dysfunction, SIADH, skin reactions, sleep disorders, suicidal behaviors, tachycardia, altered taste, testicular swelling, thrombocytopenia, tinnitus, tremor, urinary retention, blurred vision, vomiting, and weight gain. Less common side effects include psychosis, seizures, agranulocytosis, alopecia, cardiac conduction disorders, eosinophilia, glaucoma, hepatic disorders, hyperpyrexia, leukopenia, neuroleptic malignant syndrome, edema, QT interval prolongation, respiratory disorders, thrombocytopenia, and vaginal hemorrhage (Almasi et al., 2024).

Providers should educate patients about the effects of drowsiness. It is also important to note that withdrawal can occur after five days of abstaining from the medication. Tapering should be done over a period of at least four weeks (Almasi et al., 2024).

Imipramine hydrochloride is another TCA used for depression. It is also used for nocturnal enuresis.

Medicinal forms (National Library of Medicine, 2017):

• Oral Solution: Available by order
• Tablet: Imipramine hydrochloride 10 mg, 25 mg tablets 

For depression (National Library of Medicine, 2017):

• Adults: In adults, the starting dose is up to 75 mg daily in divided doses, which is then increased to 150–200 mg daily. Up to 150 mg may be given as a single dose at bedtime. The dose should be increased gradually.
• Older adults: The initial dose for the older adult population is 10 mg daily, which could be increased to 30 to 50 mg per day; however, an increase in the dose should be done slowly.

Contraindications include the immediate recovery period after myocardial infarction, acute porphyria, arrhythmia, mania, and heart block. Cautions include cardiovascular disease, constipation, epilepsy, bipolar disorder, history of psychosis, hyperthyroidism, increased intraocular pressure, a susceptibility to angle-closure glaucoma, patients with a significant suicide risk and history, pheochromocytoma, prostatic hypertrophy, and urinary retention. Caution should also be exercised with hepatic and renal impairment (National Library of Medicine, 2017).

Common side effects include anxiety, decreased appetite, arrhythmia, asthenia, cardiac conduction disorders, confusion, delirium, depression, dizziness, drowsiness, epilepsy, hallucinations, headache, hepatic disorders, hypotension, mood alterations, nausea, palpitations, paresthesia, sexual dysfunction, skin reactions, sleep disorder, tremors, vomiting, and weight changes. Less common side effects include psychosis, aggression, agranulocytosis, alopecia, bone marrow depression, enlarged mammary gland, eosinophilia, fever, galactorrhea, gastrointestinal disorders, glaucoma, heart failure, leukopenia, movement disorders, mydriasis, edema, oral disorders, peripheral vasospastic reaction, photosensitivity reaction, respiratory disorders, SIADH, speech disorder, and thrombocytopenia (National Library of Medicine, 2017).

Taking imipramine hydrochloride during pregnancy may cause colic, tachycardia, dyspnea, irritability, muscle spasms, and respiratory depression.

Providers should educate patients about the effects of drowsiness. It is also important to note that withdrawal can occur after five days of abstaining from the medication. Tapering should be done over a period of at least four weeks (Almasi et al., 2024).

Nortriptyline is another TCA utilized for depression.

Medicinal forms (Merwar et al., 2023):

• Oral solution: Nortriptyline (as nortriptyline hydrochloride) 2 mg per 1 ml (nortriptyline 10 mg/5 ml); Nortriptyline (as nortriptyline hydrochloride) 5 mg per 1 ml (nortriptyline 25 mg/5 ml).
• Tablet: Nortriptyline 10 mg, 25 mg, 50 mg.

Dosing is as follows (Merwar et al., 2023):

• Adults: Initially, 75 mg daily is prescribed in divided doses, which is then increased to 75–100 mg in divided doses or once daily. The maximum dose is 150 mg per day.
• Older adults: Initially, the dose is low, then increased to 30–50 mg daily in divided doses.

Nortriptyline is contraindicated in arrhythmias, during the manic phase of bipolar disorder, heart block, and in the immediate recovery period after myocardial infarction (Merwar et al., 2023). Caution should be used in cardiovascular disease, chronic constipation, diabetes, epilepsy, history of bipolar disorder, history of psychosis, hyperthyroidism (risk of arrhythmias), increased intraocular pressure, patients with significant risk of suicide, pheochromocytoma (risk of arrhythmias), severe hepatic impairment, prostatic hypertrophy, a susceptibility to angle-closure glaucoma, and urinary retention.

Regarding pregnancy, nortriptyline should only be used if the potential benefit outweighs the risk. Neonatal withdrawal symptoms and respiratory depression have been reported when used in the third trimester (Merwar et al., 2023).

Common side effects include anxiety, decreased appetite, arrhythmias, asthenia, atrioventricular block, bone marrow disorders, breast enlargement, confusion, constipation, delusions, diarrhea, dizziness, drowsiness, drug cross-reactivity, dry mouth, eosinophilia, fever, flushing, galactorrhea, gastrointestinal discomfort, gynecomastia, hallucination, headache, hepatic disorders, hyperhidrosis, hypertension, hypomania, hypotension, increased risk of fracture, increased risk of infection, malaise, movement disorders, mydriasis, myocardial infarction, nausea, edema, oral disorders, palpitations, paralytic ileus, peripheral neuropathy, photosensitivity reactions, psychosis, seizures, abnormal sensations, sexual dysfunction, SIADH, skin reactions, sleep disorders, stroke, suicidal behaviors, altered taste, testicular swelling, thrombocytopenia, tinnitus, tremors, urinary disorders, urinary tract dilation, vision disorders, vomiting, and weight changes (Merwar et al., 2023).

Less common side effects include psychosis, aggression, agranulocytosis, alopecia, enlarged mammary gland, eosinophilia, fever, galactorrhea, gastrointestinal disorders, glaucoma, heart failure, leukopenia, movement disorders, mydriasis, edema, oral disorders, peripheral vasospastic reaction, photosensitivity reactions, respiratory disorders, SIADH, speech disorder, and thrombocytopenia (Merwar et al., 2023).

Treatment should be stopped if the patient enters a manic phase. Older adults are particularly susceptible to many side effects of TCAs; low initial doses should be used with close monitoring, particularly for psychiatric and cardiac side effects. Plasma-nortriptyline concentration monitoring is advised if the dose exceeds 100 mg daily, though the evidence of practical value is uncertain. Withdrawal effects may occur within five days of stopping treatment with antidepressant drugs. These are usually mild and self-limiting, but may be severe in some cases. Gradually reduce the dose over four weeks or longer if withdrawal symptoms emerge. Providers should educate patients that drowsiness may affect the performance of skilled tasks (e.g., driving) and the effects of alcohol may be enhanced (Merwar et al., 2023).

Trazodone, a serotonin receptor antagonist and reuptake inhibitor (SARI), is another medication used for depression.

Medicinal forms (Shin & Saadabadi, 2024):

• Oral solution: 10 mg per 1 ml (50 mg/5 ml), 20 mg per 1 ml (100 mg/5 ml)
• Tablet: 50 mg, 100 mg, 150 mg
• Capsule: 50 mg, 100 mg 

Adults are initially prescribed 150 mg daily in divided doses or once daily at bedtime. The dose is increased if necessary to 300 mg daily or up to 600 mg in divided doses (for patients in the hospital).

Older adults are initially prescribed 100 mg daily in divided doses or once daily at bedtime. It is then increased if necessary to 300 mg or up to 600 mg in divided doses (for patients in the hospital) (Shin & Saadabadi, 2024).

Trazodone is also prescribed for anxiety. Adults are usually prescribed 75 mg daily. It can be increased to 300 mg daily if required.

Contraindications include when the patient is experiencing mania and during the immediate recovery period after myocardial infarction. Cautions include arrhythmias, constipation, epilepsy, a history of bipolar disorder, a history of psychosis, hyperthyroidism (as it increases the risk of arrhythmias), increased intraocular pressure, significant history and risk of suicide, prostatic hypertrophy, and urinary retention. Treatment should be stopped if the patient enters a manic phase. Older adults should use lower starting doses with close monitoring for psychiatric and cardiac side effects. Extreme caution should be exercised in hepatic and renal impairment. In pregnancy, trazodone should be avoided during the first trimester. The infant should be monitored for signs of withdrawal if used near delivery (Shin & Saadabadi, 2024).

Common side effects include aggression, anxiety, arrhythmias, chest pain, constipation, delirium, delusions, dizziness, drowsiness, dry mouth, headache, hallucinations, nausea, postural hypotension, priapism, QT interval prolongation, seizures, serotonin syndrome, and suicidal behavior. Less common side effects of trazodone include agranulocytosis, angioedema, manic episodes, neuroleptic malignant syndrome, paralytic ileus, skin reactions, tremors, and withdrawal syndrome (Shin & Saadabadi, 2024).

When there is an overdose, the patient may experience hypotension, respiratory failure, arrhythmias, and convulsions (Shin & Saadabadi, 2024).

Mirtazapine is a presynaptic alpha2-adrenoreceptor antagonist that increases central noradrenergic and serotonergic neurotransmission, which is indicated for major depression.

Medicinal forms (Jilani et al., 2024):

• Tablets: 15 mg, 30 mg, and 45 mg
• Oral solution: 15 mg/ml
• Orally disintegrating tablet (ODT): 15 mg, 30 mg, 45 mg 

Adults are initially prescribed 15–30 mg daily for 2–4 weeks, taken at bedtime, then adjusted according to response to up to 45 mg daily, or 45 mg in two divided doses (Jilani et al., 2024).

Caution is indicated with cardiac disorders, diabetes mellitus, older adults, a history of mania, seizures, urinary retention, hypotension, psychoses, and angle-closure glaucoma. Use with caution in pregnancy; the neonate should be monitored for withdrawal effects if used during pregnancy. Regarding breastfeeding, mirtazapine is present in breast milk; use only if the potential benefit outweighs the risk. For patients with hepatic impairment, it is advised to exercise caution due to the risk of increased plasma concentration. The clearance is reduced for patients with renal impairment, so close monitoring is warranted (Jilani et al., 2024).

Common side effects include anxiety, increased appetite, arthralgia, back pain, confusion, xerostomia, fatigue, headache (on discontinuation), myalgia, nausea, edema, postural hypotension, sleep disorders, tremors, vomiting, weight gain, constipation, diarrhea, dizziness, and drowsiness. Less common side effects include hallucinations, mania, movement disorders, oral disorders, syncope, aggression, and pancreatitis (Jilani et al., 2024).

Nausea, vomiting, dizziness, agitation, anxiety, and headache are the most common features of withdrawal if treatment is stopped abruptly. The dose should be reduced gradually over several weeks. Providers should advise patients on the proper administration of ODTs. Patients should report fever, sore throat, stomatitis, or other signs of infection during treatment. A complete blood count should be performed if blood dyscrasia is suspected, and the drug should be stopped immediately (Jilani et al., 2024).

High-dose antipsychotics are defined as exceeding the maximum licensed dose for a given patient’s age and condition. High-dose use is associated with increased side effects, including QT-interval prolongation and sudden cardiac death. They should be prescribed cautiously, with careful monitoring for side effects (Chokhawala & Stevens, 2023).

Antipsychotics for older adults, especially those with dementia, should be prescribed with caution due to the increased risk of mortality, stroke, and postural hypotension. It is recommended to use the lowest effective dose for the shortest period and to review treatment regularly. Antipsychotics should only be used in older adults with dementia at risk of harming themselves or others (Chokhawala & Stevens, 2023).

The goal of prescribing antipsychotic drugs for rapid tranquillization in emergency settings is to calm and sedate the patient without inducing sleep. Initial doses should be written as single doses, with no repeats until the effects of the first dose are reviewed. Continuous monitoring of vital signs and side effects is essential. If a high-dose antipsychotic is used, monitor every 15 minutes (Chokhawala & Stevens, 2023).

If no improvement is seen after 4–6 weeks of treatment, the antipsychotic may be considered ineffective. Patients should receive a trial period with a properly titrated dose of antipsychotic drugs to evaluate their effectiveness and tolerability (Chokhawala & Stevens, 2023).

There is no universally suitable first-line antipsychotic drug for all patients. The choice of drug should be tailored based on individual patient characteristics and preferences. Side effects, such as EPS, are important to educate the patient about and monitor for.

EPS is more likely with high doses, particularly of first-generation antipsychotic drugs (e.g., fluphenazine, haloperidol). There is a lower risk of EPS with second-generation antipsychotics (Chokhawala & Stevens, 2023).

Types of EPS include the following (Chokhawala & Stevens, 2023):

• Parkinsonian symptoms: Bradykinesia and tremors are more common in older adult females or those with pre-existing neurological issues.
• Dystonia: Uncontrolled muscle spasms, which are more common in young males. This can appear within hours.
• Akathisia: Restlessness, often mistaken for psychotic agitation; typically occurs within hours to weeks.
• Tardive dyskinesia: Abnormal involuntary movements (e.g., lips, tongue, face). This can be irreversible and develop with long-term or high-dose therapy.

Management of EPS includes reducing exposure to high-dose, high-potency antipsychotics. Antimuscarinic drugs can relieve symptoms but should not be used routinely for prophylaxis. There should be a regular review of treatment. The patient may benefit from dose reduction or withdrawal when there are early signs, such as abnormal tongue movements (Chokhawala & Stevens, 2023).

There are other common side effects. Hyperprolactinemia is caused by increased prolactin due to the blocking of dopamine. Symptoms include sexual dysfunction, menstrual disturbances, galactorrhea, and an increased breast cancer risk. Risperidone and first-generation antipsychotics are more likely to cause symptoms. Aripiprazole and clozapine have the lowest risk (Chokhawala & Stevens, 2023).

Risperidone, haloperidol, and olanzapine are more likely to cause issues such as reduced libido and problems with arousal or ejaculation. Aripiprazole and quetiapine have the lowest incidence (Chokhawala & Stevens, 2023).

Cardiovascular side effects are also possible. Tachycardia, arrhythmias, and hypotension are common. Postural hypotension may occur with clozapine and quetiapine. Slow dose titration can help minimize these effects.

There is an increased risk of diabetes with all antipsychotic drugs, particularly second-generation drugs. Amisulpride and aripiprazole carry the lowest risk (Chokhawala & Stevens, 2023).

Weight gain is common with clozapine and olanzapine; aripiprazole, asenapine, and haloperidol are less likely to cause significant weight gain.

Neuroleptic malignant syndrome is a rare but potentially fatal condition characterized by hyperthermia, muscle rigidity, autonomic dysfunction, and altered consciousness. Immediate discontinuation of the drug is necessary, and supportive treatment with bromocriptine or dantrolene may be used (Chokhawala & Stevens, 2023).

Weight should be checked weekly for the first six weeks, then at 12 weeks, one year, and yearly thereafter. Fasting blood glucose, HbA1c, lipid concentrations, and prolactin levels should be monitored at baseline, 12 weeks, one year, and annually. Blood pressure and electrocardiogram (ECG) should be monitored regularly, especially for patients with cardiovascular risks. Complete blood count, urea, electrolytes, and liver function tests should be done at the start of treatment and annually thereafter. Blood concentrations may need to be checked, particularly for drugs like clozapine (Chokhawala & Stevens, 2023).

Depot antipsychotics are long-acting injectable forms of the medication. These are often considered for patients with schizophrenia or psychosis, where adherence is a concern. Second-generation depot preparations have fewer side effects, especially EPS. Examples include paliperidone, risperidone, and olanzapine. Zuclopenthixol decanoate may be more effective in preventing relapses (Chokhawala & Stevens, 2023).

There is some cautionary advice when using these medications. They include the following (Chokhawala & Stevens, 2023):

• Blood dyscrasias: Monitor blood counts regularly. 
• Cardiovascular disease: Consider an ECG, especially in patients with risk factors or a history of cardiovascular issues.
• Conditions predisposing to seizures: Use with caution in patients with a history of seizures or epilepsy.
• Depression: May exacerbate depressive symptoms in some individuals.
• Diabetes: Can raise blood glucose levels, increasing the risk of diabetes.
• Epilepsy: Increased risk of seizures.
• History of jaundice: Use cautiously due to potential liver complications.
• Myasthenia gravis: May worsen symptoms.
• Parkinson’s disease: Can exacerbate symptoms.
• Photosensitization: Higher dosages may increase the risk of photosensitivity.
• Prostatic hypertrophy: Risk of urinary retention.
• Severe respiratory disease: Use with caution.
• Susceptibility to angle-closure glaucoma: Be cautious in patients with this condition.

There is also cautionary advice specific to older adults. Patients with Parkinsonism or Lewy body disease should avoid antipsychotics (other than quetiapine and clozapine) due to the risk of severe EPS. Patients with behavioral and psychological symptoms of dementia should avoid these medications unless symptoms are severe and non-pharmacological treatments have failed. Antipsychotics can increase the risk of stroke. Hypnotics should be avoided unless sleep disorders are due to psychosis or dementia, as antipsychotics can cause confusion, hypotension, EPS, and falls. Patients at an increased risk of falls should be monitored closely, as medications may cause gait dyspraxia, increasing fall risk. Phenothiazines should be avoided as first-line treatment due to sedative effects and significant antimuscarinic toxicity. Caution should be used with antipsychotic drugs with moderate or marked antimuscarinic effects in patients with a history of urinary retention (Chokhawala & Stevens, 2023).

EPS and withdrawal syndrome have occasionally been reported in neonates when antipsychotic drugs are taken during the third trimester. Animal studies suggest possible adverse effects of antipsychotic medicines on the developing nervous system. Chronic treatment while breastfeeding should be avoided unless necessary. Some phenothiazine derivatives can be used for short-term treatment of nausea and vomiting in breastfeeding women (Chokhawala & Stevens, 2023).

Common side effects include agitation, amenorrhea, arrhythmias, constipation, dizziness, drowsiness, dry mouth, erectile dysfunction, fatigue, galactorrhea, gynecomastia, hyperglycemia, hyperprolactinemia, hypotension (dose-related), insomnia, leukopenia, movement disorders, muscle rigidity, neutropenia, parkinsonism, postural hypotension (dose-related), QT interval prolongation, rash, seizures, tremors, urinary retention, vomiting, and weight gain. Less common side effects include agranulocytosis, confusion, embolism and thrombosis, neuroleptic malignant syndrome (discontinue immediately; potentially fatal), sudden death, and neonatal withdrawal syndrome. Side effects may persist until the drug is cleared from the depot site (Chokhawala & Stevens, 2023).

Regarding overdose, phenothiazines cause less depression of consciousness and respiration than other sedatives but can lead to hypotension, hypothermia, sinus tachycardia, and arrhythmias. Immediate medical intervention is necessary (Chokhawala & Stevens, 2023).

Prolactin levels should be monitored at the start of therapy, at six months, and annually thereafter. Patients should be monitored if symptoms of hyperprolactinemia (e.g., breast enlargement, galactorrhea) appear.

When these drugs are prescribed in children, regular clinical monitoring of endocrine function is important when antipsychotic drugs known to increase prolactin levels are used. This includes measuring weight, height, sexual maturation, and menstrual function (Chokhawala & Stevens, 2023).

There is a high risk of relapse if medication is stopped after 1-2 years. Antipsychotic drug withdrawal after long-term therapy should always be gradual and closely monitored to avoid acute withdrawal symptoms or rapid relapse. Patients should be monitored for signs and symptoms of relapse for two years after withdrawal (Chokhawala & Stevens, 2023).

Chlorpromazine hydrochloride is indicated for schizophrenia and other psychoses, mania, severe anxiety, psychomotor agitation, and violent behavior.

By mouth (Mann & Marwaha, 2023):

• Adults: Initially, 25 mg three times a day is prescribed, and then increased based on response.
• Maintenance: The dose is 75–300 mg daily; it can be increased to 1 g daily if necessary for psychoses.
• Older adults: Use a third to half of the adult dose.

By rectum (Mann & Marwaha, 2023):

• Adults: 100 mg every 6–8 hours.

For the relief of acute symptoms of psychoses, deep intramuscular injection is often used (Mann & Marwaha, 2023).

• Adults: 25–50 mg every 6–8 hours.

Contraindications include CNS depression, comatose states, hypothyroidism, and pheochromocytoma. Cautions include risk factors for stroke, cardiac disorders, cerebral arteriosclerosis, use in older adults, hyperthyroidism, hypothyroidism, Parkinsonism, pheochromocytoma, QT interval prolongation, and senile confusional states. Use with caution in severe hepatic failure due to the increased risk of accumulation. Also, caution should be used in severe renal failure, as there is an increased risk of cerebral sensitivity (Mann & Marwaha, 2023).

Common side effects include anxiety, impaired glucose tolerance, mood alteration, and increased muscle tone. Less common side effects include flatulence, hot flashes, nausea, oculogyric crisis, photosensitivity, impaired glucose tolerance, jaundice, and thrombocytopenia. Acute dystonic reactions are more common in children (Mann & Marwaha, 2023).

It is important to note that intramuscular use may cause nasal congestion. For intramuscular use, monitor blood pressure for 30 minutes after injection, and ensure the patient remains supine (Mann & Marwaha, 2023).

Due to the risk of contact sensitization, avoid direct contact with chlorpromazine. Tablets should not be crushed, and solutions should be handled carefully (Mann & Marwaha, 2023).

Prochlorperazine is indicated for the treatment of schizophrenia and other psychoses and mania. It comes in tablets, buccal tablets, and a solution for injection.

By mouth (Din & Preuss, 2023):

• Adults: 12.5 mg twice daily for seven days, dose to be adjusted at weekly intervals according to the response. The usual dose is 75–100 mg daily.

By deep intramuscular injection (Din & Preuss, 2023):

• Adults: 12.5–25 mg 2–3 times a day.

With buccal use, tablets should be placed high between the upper lip and gum and left to dissolve.

Prochlorperazine can also be used as a short-term adjunctive management of severe anxiety.

By mouth (Din & Preuss, 2023):

• Adults: 15–20 mg daily in divided doses; maximum 40 mg daily.

Contraindications include the oral route in children under 10 kg, CNS depression, comatose states, and pheochromocytoma. Cautions include use in older adults, hypotension (more likely after intramuscular injection), and hypothyroidism (in adults). It should be avoided in patients with hepatic impairment. With renal impairment, start with small doses due to increased cerebral sensitivity (Din & Preuss, 2023).

General side effects may include impaired glucose tolerance, hyponatremia, and SIADH. There are some specific side effects associated with the routes of administration (Din & Preuss, 2023).

• With buccal use: Blood disorders, hepatic disorders.
• With intramuscular use: Atrioventricular block, cardiac arrest, eye disorders, jaundice, nasal congestion, respiratory depression, and skin reactions.
• With oral use: Atrioventricular block, autonomic dysfunction, cardiac arrest, impaired consciousness, hyperthermia, jaundice, nasal congestion, oculogyric crisis, respiratory depression, and skin reactions.

Haloperidol decanoate is used as a maintenance medication in schizophrenia and schizoaffective disorder (for patients stabilized on oral haloperidol).

This medication comes as a solution for injection (Haldol decanoate 50 mg per 1 ml and Haldol decanoate 100 mg per 1 ml). It is given as a deep intramuscular injection (Rahman & Marwaha, 2023):

• Adults: Initially, 25–150 mg is given every four weeks, based on the previous daily dose of oral haloperidol. Adjust in steps of up to 50 mg every four weeks as needed. The usual maintenance dose is 50–200 mg every four weeks. The maximum is 300 mg every four weeks.
• Older adults: Initially, 12.5–25 mg is prescribed every four weeks, and is then increased as necessary to 25–75 mg every four weeks. Doses above 75 mg every four weeks should be reconsidered after reassessment.

If supplementation with oral haloperidol is required, the combined dose from both formulations must not exceed the corresponding maximum oral dose of 20 mg per day for adults and 5 mg per day for older adults (Rahman & Marwaha, 2023).

Contraindications include CNS depression, comatose states, congenital long QT syndrome, dementia with Lewy bodies, a history of torsade de pointes, a history of ventricular arrhythmia, Parkinson’s disease, progressive supranuclear palsy, QT-interval prolongation, recent acute myocardial infarction, uncompensated heart failure, and uncorrected hypokalemia. Cautions include bradycardia, electrolyte disturbances, a family history of QTc interval prolongation, a history of heavy alcohol exposure, hyperthyroidism, hypotension (including orthostatic hypotension), prolactin-dependent tumors, and risk factors for stroke. When transferring from oral to depot therapy, reduce the oral dose gradually. Exercise caution with renal and hepatic impairment; halve the initial dose and adjust with smaller increments at longer intervals. (Rahman & Marwaha, 2023).

Common side effects include depression, hypersalivation, and sexual dysfunction. Less common side effects include eye disorders, headache, neuromuscular dysfunction, and vision disorders (Rahman & Marwaha, 2023).

It is preferable to avoid this medication in patients who are pregnant. There are isolated reports of congenital disabilities, mostly in combination with other drugs. Reproductive toxicity has been shown in animal studies (Rahman & Marwaha, 2023).

Providers should perform an ECG before treatment initiation and assess the need for further ECGs during treatment on an individual basis. Monitor electrolytes before treatment initiation and periodically during treatment (Rahman & Marwaha, 2023).

Aripiprazole is a dopamine D2 partial agonist with weak 5-HT1a partial agonism and 5-HT2A receptor antagonism. It is used in the maintenance of schizophrenia, often in patients stabilized with oral aripiprazole (CYP2D6 poor metabolizers) (Gettu & Saadabadi, 2023).

Medicinal forms (Gettu & Saadabadi, 2023):

Tablet: Aripiprazole 5 mg, 10 mg, 15 mg, 30 mg

Solution for injection: Aripiprazole 7.5 mg/1 ml

Oral solution: Aripiprazole 1 mg/ml

Powder and solvent for suspension for injection: Abilify Maintena 400 mg

For the maintenance of schizophrenia (Gettu & Saadabadi, 2023):

By intramuscular injection:

• Adults: 400 mg every month, to be injected into the gluteal or deltoid muscle. There is a minimum of 26 days between injections. Treatment with 10–20 mg oral aripiprazole daily should continue for 14 consecutive days after the first injection. 

By mouth:

• Adults: 10–15 mg once daily are prescribed. The usual dose is 15 mg once daily, with the maximum per dose being 30 mg once daily.

For the treatment and recurrence prevention of mania (Gettu & Saadabadi, 2023):

By mouth:

• Adults: The dose of aripiprazole for the treatment and prevention of mania in adults is 15 mg once daily, and then increased if necessary up to 30 mg once daily.

Common side effects include anxiety, abnormal appetite, diabetes mellitus, gastrointestinal discomfort, headache, hypersalivation, nausea, and vision disorders. Less common side effects include depression, hiccups, and sexual dysfunction (Gettu & Saadabadi, 2023).

Regarding pregnancy, use only if the potential benefit outweighs the risk. It is advised to avoid use during breastfeeding as it is present in milk.

Exercise caution in severe hepatic impairment; oral treatment is preferred to intramuscular administration in these situations (Gettu & Saadabadi, 2023).

Aripiprazole does not affect blood pressure to the same extent as other antipsychotic drugs, but blood pressure monitoring may still be necessary. With intramuscular use, treatment requires careful monitoring for optimum effect (Rahman & Marwaha, 2023).

Cariprazine is used in the treatment of schizophrenia. It is most commonly dispensed as a capsule (cariprazine hydrochloride 1.5 mg, 3 mg, 4.5 mg, 6 mg) (Laszlovszky et al., 2021).

By mouth (Laszlovszky et al., 2021):

• Adults: 1.5 mg is prescribed once daily. This is increased in steps of 1.5 mg if required, to a maximum of 6 mg per day.

Common side effects include anxiety, abnormal appetite, bradyphrenia, drooling, dyslipidemia, eye disorders, gait abnormality, hypertension, joint stiffness, muscle tightness, musculoskeletal stiffness, nausea, oral disorders, pain, abnormal reflexes, sleep disorders, speech impairment, teeth grinding, and vision disorders. Less common side effects include anemia, cardiac conduction disorder, delirium, depression, diabetes mellitus, dysesthesia, eosinophilia, eye irritation, gastroesophageal reflux disease, grimacing, hiccups, pruritus, sexual dysfunction, suicidal behavior, thirst, urinary disorders, vertigo, cataracts, dysphagia, hypothyroidism, memory loss, and rhabdomyolysis (Laszlovszky et al., 2021).

A highly effective contraception is advised for women of childbearing potential during treatment and for at least ten weeks after the last dose. The addition of a barrier method is recommended for women using systemically acting hormonal contraceptives. It is advised to avoid taking cariprazine during pregnancy and breastfeeding. It is also advised to avoid in severe hepatic and renal impairment (Laszlovszky et al., 2021).

Clozapine is a dopamine D1, dopamine D2, 5-HT2A, alpha1-adrenoceptor, and muscarinic-receptor antagonist. It is often indicated in patients with schizophrenia who are unresponsive to, or intolerant of, conventional antipsychotic drugs (Haidary & Padhy, 2023).

Medicinal forms (Haidary & Padhy, 2023):

• Tablet: 25 mg, 100 mg
• Oral suspension: 50 mg/1 ml
• ODT: 12.5 mg, 25 mg, 50 mg 

By mouth (Haidary & Padhy, 2023):

• Adults 18–59 years: 12.5 mg 1–2 times a day for one day, then 25–50 mg for day two, increased to 200–450 mg daily over 14–21 days, going up to 900 mg daily if necessary.
• Adults 60 years and over: 12.5 mg once daily for one day, increased to 25–37.5 mg for day two, increased gradually to 300 mg daily in divided doses, with a maximum of 900 mg daily.

Contraindications include alcoholic and toxic psychoses, bone marrow disorders, coma, drug intoxication, a history of agranulocytosis, a history of circulatory collapse or neutropenia, paralytic ileus, severe cardiac disorders (e.g., myocarditis), severe CNS depression, and uncontrolled epilepsy (Haidary & Padhy, 2023).

Cautions include age over 60 years, prostatic hypertrophy, and a susceptibility to angle-closure glaucoma. Clozapine should be used with caution in pregnancy and avoided during breastfeeding. It should also be avoided in severe renal impairment. With hepatic impairment, exercise caution. Monitor liver function and discontinue if liver enzymes are greater than three times the upper limit of normal or if jaundice occurs. It should also be avoided in symptomatic or progressive impairment and hepatic failure (Haidary & Padhy, 2023).

Common side effects include decreased appetite, eosinophilia, fever, headache, hypertension, leukocytosis, nausea, oral disorders, speech impairment, abnormal sweating, syncope, temperature regulation disorders, urinary disorders, and blurred vision. Less common side effects include falls, anemia, cardiac arrest, cardiac inflammation, cardiomyopathy, circulatory collapse, delirium, diabetes mellitus, dyslipidemia, dysphagia, gastrointestinal disorders, impaired glucose tolerance, hepatic disorders, increased risk of infection, intestinal obstruction (including fatal cases), ketoacidosis, tubulointerstitial nephritis, OCD, pancreatitis, pericardial effusion, respiratory disorders, restlessness, sexual dysfunction, skin reactions, sleep apnea, thrombocytopenia, and thrombocytosis (Haidary & Padhy, 2023).

Monitor leukocyte and differential blood counts (weekly for 18 weeks, then twice a month for up to a year, then monthly). Blood clozapine concentration should be monitored in certain clinical situations. Blood lipids and weight should be measured at baseline, at three months, and then yearly with antipsychotics. Fasting blood glucose should be measured at baseline, at 4–6 months, and then yearly. Taper off other antipsychotics before starting clozapine (Haidary & Padhy, 2023).

Lurasidone is a dopamine D2, 5-HT2A, 5-HT7, alpha2A- and alpha2C-adrenoceptor antagonist, and is a partial agonist at 5-HT1A receptors. It is indicated to treat schizophrenia and comes in the form of a tablet (lurasidone hydrochloride 18.5 mg, 37 mg, and 74 mg) (Azhar & Shaban, 2023).

By mouth:

• Adults: Initially, 37 mg once daily is prescribed and increased up to 148 mg once daily if necessary.

When used to treat schizophrenia in patients using moderate CYP3A4 inhibitors like diltiazem, erythromycin, fluconazole, and verapamil, the dose should be reduced.

Caution should be used in high doses in older adults and those susceptible to QT-interval prolongation. Lurasidone should only be used in pregnancy and breastfeeding if the potential benefit outweighs the risk (Azhar & Shaban, 2023).

With hepatic impairment, exercise caution and adjust the dose. Initially, 18.5 mg once daily is used in moderate to severe impairment, and increased if necessary to 74 mg once daily in moderate impairment, or up to a maximum of 37 mg once daily in severe impairment (Azhar & Shaban, 2023).

With renal impairment, use only if the potential benefit outweighs the risk if creatinine clearance is less than 15 mL/min. The dose may need to be adjusted. Initially, 18.5 mg is taken once daily, up to a maximum of 74 mg once daily if creatinine clearance is less than 50 mL/min (Azhar & Shaban, 2023).

Common side effects include anxiety, drooling, gastrointestinal discomfort, hypersensitivity, musculoskeletal stiffness, nausea, oculogyric crisis, oral disorders, pain, pruritus, psychiatric disorders, and sleep disorders. Less common side effects include decreased appetite, dysarthria, dysuria, gait abnormalities, gastrointestinal disorders, hot flashes, hyperhidrosis, hypertension, hyponatremia, joint stiffness, myalgia, nasopharyngitis, and blurred vision (Azhar & Shaban, 2023).

Olanzapine is a dopamine D1, D2, D4, 5-HT2, histamine-1-, and muscarinic-receptor antagonist. It is indicated for schizophrenia and as a combination therapy for mania (Thomas & Saadabadi, 2023).

Medicinal forms (Thomas & Saadabadi, 2023):

• Tablet: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, and 20 mg
• ODT: Olanzapine 5 mg, 10 mg, 15 mg, and 20 mg

By mouth (Thomas & Saadabadi, 2023):

• Adults: The usual adult dose of olanzapine for schizophrenia or when given as a combination therapy for the management of mania is 10 mg daily. However, it should be adjusted according to the response. The usual dose for adults is 5 to 20 mg daily, and doses greater than 10 mg daily are only given after reassessment, with a maximum of 20 mg per day.

Olanzapine is also used in bipolar disorder.

By mouth (Thomas & Saadabadi, 2023):

• Adults: 10 mg daily is prescribed and adjusted according to the response. The usual dose is 5–20 mg daily. Doses greater than 10 mg daily are prescribed only after reassessment.

It can also be used as a monotherapy for mania.

By mouth (Thomas & Saadabadi, 2023):

• Adults: 15 mg is given daily and adjusted according to response. The usual dose is 5–20 mg daily, with a maximum dose of 20 mg per day.

Olanzapine can also be used to help minimize agitation and disturbed behavior in schizophrenia or mania.

By intramuscular injection (Thomas & Saadabadi, 2023):

• Adult: Initially, 5–10 mg for one dose is given, followed by 5–10 mg after two hours if required. The maximum dose is three injections daily for three days. The maximum daily combined oral and parenteral dose is 20 mg.

Contraindications with intramuscular use include acute myocardial infarction, bradycardia, recent heart surgery, severe hypotension, sick sinus syndrome, and unstable angina. Cautions include bone marrow depression, hypereosinophilic disorders, low leukocyte count, low neutrophil count, myeloproliferative disease, and paralytic ileus.

With intramuscular use, blood pressure, pulse, and respiratory rate should be monitored for at least four hours after injection, particularly in those also receiving a benzodiazepine or another antipsychotic (Thomas & Saadabadi, 2023).

With pregnancy, olanzapine should only be used if the potential benefit outweighs the risk. Neonatal lethargy, tremors, and hypertonia have been reported when this medication has been used in the third trimester. Olanzapine use should be avoided while the patient is breastfeeding, as it has been found in breast milk.

For patients with hepatic or renal impairment, caution is warranted, and dose adjustments may be necessary.

Common side effects include anticholinergic syndrome, increased appetite, arthralgia, asthenia, eosinophilia, fever, glycosuria, edema, and sexual dysfunction. Less common side effects include abdominal distension, alopecia, breast enlargement, diabetes mellitus, dysarthria, epistaxis, memory loss, photosensitivity reaction, urinary disorders, hepatic disorders, hypothermia, pancreatitis, rhabdomyolysis, and thrombocytopenia. Dyslipidemia may occur with intramuscular use, and hypersomnia may occur with oral use (Thomas & Saadabadi, 2023).

Blood lipids and weight should be measured at baseline, at three months, and then yearly with antipsychotic drugs. Fasting blood glucose should be measured at baseline, at 4–6 months, and then yearly (Thomas & Saadabadi, 2023).

Quetiapine is an antipsychotic drug that acts as a dopamine D1, dopamine D2, 5-HT2, alpha1-adrenoceptor, and histamine-1 receptor antagonist. It is used for schizophrenia, mania in bipolar disorder, and depression. Quetiapine comes in the following forms (Maan et al., 2023):

• Tablet: Quetiapine, Seroquel
• Oral Suspension: Quetiapine 

Schizophrenia

By mouth using immediate-release medications (Maan et al., 2023):

• Adults: The dose of Quetiapine for the treatment of schizophrenia is 25 mg twice daily for day one, which is then followed by 50 mg twice daily for day two, then 100 mg twice daily for day three, then 150 mg twice daily for day four. It should be adjusted according to the patient’s response. However, the usual adult dose of quetiapine is 300 to 450 mg daily, given in two divided doses.

By mouth using modified-release medications (Maan et al., 2023):

• Adults: The dose of quetiapine in adults, when given through modified-release medications, is 300 mg once daily for day one, followed by 600 mg once daily for day two, and then adjusted according to the patient’s response. However, the usual dose of quetiapine in adults in the form of modified release preparation is 600 mg once daily, which is the maximum dose under specialist supervision. However, in some cases, the maximum dose could be 800 mg per day given under specialist supervision.
• Older adults: For older adults, the initial dose of quetiapine is 50 mg once daily. However, it should be adjusted according to response and in steps of 50 mg daily.

Mania in bipolar disorder

By mouth using immediate-release medications (Maan et al., 2023):

• Adults: For the treatment of mania in bipolar disorder, the dose of quetiapine in adults is 50 mg twice daily for day one, which is then followed by 100 mg twice daily for day two, then 150 mg twice daily for day three, and 200 mg twice daily for day four. Moreover, the dose should be adjusted in steps of up to 200 mg daily and according to response. However, the usual dose for adults is 400 to 800 mg daily in two divided doses. The maximum dose of quetiapine that can be given to adults for the treatment of mania in bipolar disorder is 800 mg per day.

By mouth using modified-release medications (Maan et al., 2023):

• Adults: The dose of quetiapine in adults for the treatment of mania in bipolar disorder through modified release preparations is 300 mg once daily for day one, which is then followed by 600 mg once daily for day two, and adjusted according to response. However, the usual dose is 400 to 800 mg once daily.
• Older adults: The initial dose of quetiapine for the older population is 50 mg once daily. It should be adjusted according to response and in steps of 50 mg daily.

Depression in bipolar disorder

By mouth using immediate-release medications (Maan et al., 2023):

• Adults: The dose of quetiapine for the treatment of depression in bipolar disorder in adults is 50 mg once daily for day one, which has to be taken at bedtime, then 100 mg once daily for day two, then 200 mg once daily for day three, then 300 mg once daily for day four, and finally it should be adjusted according to response. Moreover, the usual dose of quetiapine in adults for the treatment of depression in bipolar disorder is 300 mg once daily. The maximum dose to be given is usually 600 mg daily.

Risperidone works as a dopamine D2, 5-HT2A, alpha1-adrenoceptor, and histamine-1 receptor antagonist. It is indicated for schizophrenia and other psychoses.

Medicinal forms include oral solution, injections, and tablets (McNeil et al., 2024).

By deep intramuscular injection (McNeil et al., 2024):

• Adults: The initial dose of risperidone for adults, when given through deep intramuscular injection, is 25 mg every two weeks. Moreover, it has to be administered into the deltoid or gluteal muscle and adjusted in steps of 12.5 mg. However, the maximum dose that can be given per dose is 50 mg every two weeks at intervals of at least four weeks.

Risperidone is also indicated for acute and chronic psychosis.

By mouth (McNeil et al., 2024):

• Adults: The initial adult dose of risperidone for the treatment of acute and chronic psychosis is 2 mg daily, given in 1–2 divided doses for day one, then 4 mg daily in 1–2 divided doses for day two.
• Older adults: For the older population, the initial dose of risperidone for the treatment of acute and chronic psychosis is 500 micrograms given twice daily, then increased in steps of 500 micrograms twice daily, which can be increased up to 1-2 mg twice daily.

Cautions include acute porphyria, cataract surgery (risk of intraoperative floppy iris syndrome), dehydration, dementia with Lewy bodies, and prolactin-dependent tumors. Regarding pregnancy and breastfeeding, risperidone should only be used if the potential benefit outweighs the risk. It should also be used cautiously in patients with hepatic and renal impairment (McNeil et al., 2024).

Common side effects include anemia, anxiety, abnormal appetite, asthenia, chest discomfort, conjunctivitis, cough, depression, diarrhea, dyspnea, epistaxis, fall, fever, gastrointestinal discomfort, headache, hypertension, increased risk of infection, joint disorders, laryngeal pain, muscle spasms, nasal congestion, nausea, edema, oral disorders, pain, sexual dysfunction, skin reactions, sleep disorders, urinary disorders, vision disorders, and decreased weight. Less common side effects include alopecia, breast abnormalities, cardiac conduction disorders, cerebrovascular insufficiency, chills, coma, impaired concentration, impaired consciousness, cystitis, diabetes mellitus, dry eye, dysarthria, dysphagia, dysphonia, ear pain, eye disorders, feeling abnormal, flushing, abnormal gait, gastrointestinal disorders, induration, malaise, menstrual cycle irregularities, altered mood, muscle weakness, palpitations, polydipsia, abnormal posture, procedural pain, respiratory disorders, abnormal sensations, syncope, altered taste, thirst, thrombocytopenia, tinnitus, vaginal discharge, and vertigo (McNeil et al., 2024).