| Antipsychotic drugs | ||
| Atypical antipsychotic agents | ||
| Recommended uses: control of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness | ||
| General cautions: diminished risk of developing extrapyramidal symptoms and tardive dyskinesia compared with typical antipsychotic agents | ||
| Warning: atypical antipsychotic agents can cause an increased risk of cerebrovascular events (including stroke) in elderly patients with dementia-related psychosis | ||
| Risperidone (Risperdal) | Initial dosage: 0.25 mg/day at bedtime; maximum dosage: 2–3 mg/day, usually twice daily in divided doses | Comments: current research supports use of low dosages; extrapyramidal symptoms may occur at 2 mg/day |
| Olanzapine (Zyprexa) | Initial dosage: 2.5 mg/day at bedtime; maximum dosage: 10 mg/day, usually twice daily in divided doses | Comments: generally well tolerated |
| Quetiapine (Seroquel) | Initial dosage: 12.5 mg twice daily; maximum dosage: 200 mg twice daily | Comments: more sedating; beware of transient orthostasis |
| Typical antipsychotic agents | ||
| Recommended uses: control of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness; second-line therapy for patients who cannot tolerate or who do not respond to atypical antipsychotic agents | ||
| General cautions: current research suggests that these drugs be avoided if possible because they are associated with significant, often severe side effects involving the cholinergic, cardiovascular, and extrapyramidal systems; there is also an inherent risk of irreversible tardive dyskinesia, which can develop in 50% of elderly patients after continuous use of typical antipsychotic agents for 2 years | ||
| Warning: typical antipsychotic agents can cause an increased risk of cerebrovascular events (including stroke) in elderly patients with dementia-related psychosis | ||
| Haloperidol (Haldol), fluphenazine (Prolixin), thiothixene (Navane) | Dosage: varies by agent | Comments: anticipated extrapyramidal symptoms; if these symptoms occur, decrease dosage or switch to another agent; avoid use of benztropine (Cogentin) or trihexyphenidyl (Artane) |
| Trifluoperazine (Stelazine), molindone (Moban), perfenazine (Trilafon), loxapine (Loxitane) | Dosage: varies by agent | Comments: agents with “in-between” side-effect profile |
| Mood-stabilizing (anti-agitation) drugs | ||
| Recommended uses: control of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness; useful alternatives to antipsychotic agents for control of severe agitated, repetitive, and combative behaviors | ||
| General cautions: see comments about specific agents | ||
| Trazodone (Desyrel) | Initial dosage: 25 mg/day; maximum dosage: 200 to 400 mg/day in divided doses | Comments: use with caution in patients with premature ventricular contractions |
| Carbamazepine (Tegretol) | Initial dosage: 100 mg twice daily; titrate to therapeutic blood level (4–8 μg/mL) | Comments: monitor complete blood cell count and liver enzyme levels regularly; carbamazepine has problematic side effects |
| Divalproex sodium (Depakote) | Initial dosage: 125 mg twice daily; titrate to therapeutic blood level (40–90 μg/mL) | Comments: generally better tolerated than other mood stabilizers; monitor liver enzyme levels; monitor platelets, prothrombin time, and partial thromboplastin time as indicated |
| Anxiolytic drugs | ||
| Benzodiazepines | ||
| Recommended uses: management of insomnia, anxiety and agitation | ||
| General cautions: regular use can lead to tolerance, addiction, depression and cognitive impairment; paradoxic agitations occurs in about 10% of patients treated with benzodiazepines; infrequent, low doses of agents with a short half-life are least problematic | ||
| Lorazepam (Ativan), oxazepam (Serax), temazepam (Restoril), zolpidem (Ambien), triazolam (Halcion) | Dosage: varies by agent | See general cautions |
| Nonbenzodiazepines | ||
| Buspirone (BuSpar) | Initial dosage: 5 mg twice daily; maximum dosage: 20 mg 3 times daily | Comments: useful only in patients with mild to moderate agitation; may take 2 to 4 weeks to become effective |
| Antidepressant drugs | ||
| Recommended uses: see comments on specific agents | ||
| General cautions: selection of an antidepressant is usually based on previous treatment response, tolerance and the advantage of potential side effects (eg, sedation vs activation); a full therapeutic trial requires 4–8 weeks; as a rule, dosage is increased using increments of initial dose every 5–7 days until therapeutic benefits or significant side effects become apparent; after 9 months, dosage reduction is used to reassess the need to medicate; discontinuing an antidepressant over 10–14 days limits withdrawal symptoms. | ||
| Note: patients with depression and psychosis require concomitant antipsychotic medications. | ||
| Tricyclic antidepressant agents | ||
| Desipramine (Norpramin) | Initial dosage: 10–25 mg in the morning; maximum dosage: 150 mg in the morning | Comments: tends to be activating (eg, reduces apathy); lower risk for cardiotoxic, hypotensive and anticholinergic effects; may cause tachycardia; blood levels may be helpful |
| Nortriptyline (Pamelor) | Initial dosage: 10 mg at bedtime; anticipated dosage range: 10–40 mg/day (given twice daily) | Comments: tolerance profile is similar to that of desipramine, but nortriptyline tends to be more sedating; may be useful in patients with agitated depression and insomnia; therapeutic blood level “window” of 50–150 ng/mL (190–570 nmol/L) |
| Heterocyclic and noncyclic antidepressant agents | ||
| Nefazodone (Serzone) | Initial dosage: 50 mg twice daily; maximum dosage: 150–300 mg twice daily | Comments: effective, especially in patients with associated anxiety; reduced dose of coadministered alprazolam (Xanax) or triazolam by 50%; monitor for hepatotoxicity |
| Buproprion (Wellbutrin) | Initial dosage: 37.5 mg every morning, then increase by 37.5 mg every 3 days; maximum dosage: 150 mg twice daily | Comments: activating; possible rapid improvement of energy level; should not be used in agitated patients and those with seizure disorders; to minimize risk of insomnia, give second dose before 3pm |
| Mirtazapine (Remeron) | Initial dosage: 7.5 mg at bedtime; maximum dosage: 30 mg at bedtime | Comments: potent and well tolerated; promotes sleep, appetite, and weight gain |
| SSRIs | ||
| Recommended uses: may prolong half-life of other drugs by inhibiting various cytochrome P450 isoenzymes | ||
| General cautions: typical side effects include sweating, tremors, nervousness, insomnia or somnolence, dizziness, and various gastrointestinal and sexual disturbances | ||
| Fluoxetine (Prozac) | Initial dosage: 10 mg every other morning; maximum dosage: 20 mg every morning | Comments: activating, very long half-life; side effects may not manifest for a few weeks |
| Paroxetine (Paxil) | Initial dosage: 10 mg/day; maximum dosage: 40 mg/day (morning or evening) | Comments: less activating but more anticholinergic than other SSRIs |
| Sertraline (Zoloft) | Initial dosage: 25–50 mg/day; maximum dosage: 200 mg/day (morning or evening) | Comments: well tolerated; compared with other SSRIs, sertraline has less effect on metabolism of other medications |
| Citalopram (Celexa) | Initial dosage: 10 mg/day; maximum dosage: 40 mg/day | Comments: well tolerated; some patients experience nausea and sleep disturbances |
| Fluvoxamine (Luvox) | Initial dosage: 50 mg twice daily; maximum dosage: 150 mg twice daily | Comments: exercise caution when using fluvoxamine with alprazolam or triazolam |
Reproduced with permission from Cummings JL, et al. Am Fam Physician 2002; 65:2525 to 2534. © 2002 American Academy of Family Physicians.6
SSRI, selective serotonin reuptake inhibitor.