Medications for Mental Illness: Starting Doses and Critical Considerations

Selective Serotonin Reuptake Inhibitors (SSRIs)

• The American Academy of Family Physicians recommends starting fluoxetine at 10 mg every other morning (or 10 mg daily) in adults, with a maximum of 20 mg daily for most patients 1
• Fluoxetine is activating with a very long half-life, meaning side effects may not manifest for several weeks, according to the American Family Physician 1, 2
• Morning dosing is preferred to minimize insomnia risk, as suggested by the American Family Physician 1
• The American Family Physician recommends that doses of 20-60 mg have been used in clinical trials, but 20 mg/day is sufficient for most patients 2
• Paroxetine should be initiated at 10 mg per day, with a maximum of 40 mg per day, according to the American Family Physician 1
• Paroxetine is less activating but more anticholinergic than other SSRIs, as noted by the American Family Physician 1
• Sertraline starts at 25-50 mg per day, with a maximum of 200 mg per day, as recommended by the American Family Physician 1
• Sertraline is well tolerated and has less effect on metabolism of other medications compared to other SSRIs, according to the American Family Physician 1
• Citalopram begins at 10 mg per day, with a maximum of 40 mg per day, as suggested by the American Family Physician 1
• Citalopram is well tolerated, though some patients experience nausea and sleep disturbances, as noted by the American Family Physician 1
• Typical side effects of SSRIs include sweating, tremors, nervousness, insomnia or somnolence, dizziness, gastrointestinal disturbances, and sexual dysfunction, according to the American Family Physician 1

Benzodiazepines

• The American Academy of Sleep Medicine recommends starting alprazolam at 0.25 mg at bedtime, with a range of 0.25-4.0 mg, though the usual recommended dose is 0.5-2.0 mg 30 minutes before bedtime 3
• Short-acting benzodiazepines like alprazolam carry risks of tolerance and paradoxical agitation in approximately 10% of patients, as noted by Praxis Medical Insights 4
• Concurrent benzodiazepine use with opioids increases overdose death risk nearly four-fold, according to Praxis Medical Insights 4
• Abrupt withdrawal can cause rebound anxiety, hallucinations, seizures, delirium tremens, and rarely death, as warned by Praxis Medical Insights 4
• When tapering is necessary, reduce the dose by 25% every 1-2 weeks, as recommended by Praxis Medical Insights 4
• Lorazepam for acute anxiety or agitation: 0.25-0.5 mg PRN orally or sublingually for rapid onset, with lower doses minimizing sedation while providing anxiolytic effects, according to Praxis Medical Insights 4
• Maximum daily dosage typically should not exceed 2 mg lorazepam equivalent, as suggested by Praxis Medical Insights 4
• Frequency should be limited to not more than 2-3 times weekly for PRN use, as recommended by Praxis Medical Insights 4
• Benzodiazepines should be time-limited (days to weeks) to avoid tolerance and dependence, according to Praxis Medical Insights 4

Atypical Antipsychotics

• Risperidone for acute psychosis or mania: start at 0.5-2.0 mg/day, as recommended by Praxis Medical Insights 4
• Risperidone in combination with lithium or valproate is effective for acute mania, according to Praxis Medical Insights 4
• Aripiprazole for acute mania: 5-15 mg/day, with a favorable metabolic profile compared to olanzapine, as noted by Praxis Medical Insights 4
• Aripiprazole has low lethality in overdose, making it safer when suicide risk is a concern, according to Praxis Medical Insights 4

Mood Stabilizers

• Lithium for bipolar disorder: start at 150 mg per day in elderly patients, with target levels of 0.8-1.2 mEq/L for acute treatment, as recommended by the American Family Physician and Praxis Medical Insights 1, 4
• Blood levels of 0.2-0.6 mEq/L are generally adequate for elderly patients and usually achieved with 150-300 mg per day, according to the American Family Physician 1
• Baseline monitoring requires complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females, as suggested by Praxis Medical Insights 4
• Ongoing monitoring every 3-6 months should include lithium levels, renal and thyroid function, and urinalysis, according to Praxis Medical Insights 4
• Lithium reduces suicide attempts 8.6-fold and completed suicides 9-fold, as noted by Praxis Medical Insights 4
• Valproate (Depakote): initial dosage 125 mg twice daily, titrate to therapeutic blood level, as recommended by Praxis Medical Insights 4
• Baseline monitoring requires liver function tests, complete blood count, and pregnancy test, according to Praxis Medical Insights 4
• Ongoing monitoring every 3-6 months should include serum drug levels, hepatic function, and hematological indices, as suggested by Praxis Medical Insights 4
• Valproate is particularly effective for irritability, agitation, aggressive behaviors, and mixed or dysphoric mania, according to Praxis Medical Insights 4

Other Antidepressants

• Bupropion (Wellbutrin): 37.5 mg every morning, then increase by 37.5 mg every 3 days, with a maximum of 150 mg twice daily, as recommended by the American Family Physician 1
• Activating with possible rapid improvement of energy level, as noted by the American Family Physician 1
• Should not be used in agitated patients and those with seizure disorders, according to the American Family Physician 1
• To minimize insomnia risk, give second dose before 3 p.m., as suggested by the American Family Physician 1
• Mirtazapine (Remeron): 7.5 mg at bedtime, with a maximum of 30 mg at bedtime, as recommended by the American Family Physician 1
• Potent and well tolerated; promotes sleep, appetite, and weight gain, according to the American Family Physician 1

Critical Pitfalls to Avoid

• Never use antidepressant monotherapy in bipolar disorder due to risk of mood destabilization, mania induction, and rapid cycling, as warned by Praxis Medical Insights 4
• Avoid typical antipsychotics in young patients due to