Prescribing Antidepressants and Antipsychotics in Clinical Practice

Antidepressant Management

The American Academy of Child and Adolescent Psychiatry recommends starting antidepressants at low doses and titrating gradually to minimize side effects and maximize adherence 1
Start with subtherapeutic doses as a "test dose" to minimize initial anxiety/agitation, especially with SSRIs 1
Increase doses at 1-2 week intervals for shorter half-life SSRIs and 3-4 week intervals for longer half-life SSRIs 1
Monitor for common side effects including gastrointestinal symptoms, insomnia, and sexual dysfunction 3
Use standardized symptom rating scales to systematically assess treatment response 1
Be vigilant for discontinuation syndrome with shorter-acting SSRIs characterized by dizziness, sensory disturbances, anxiety, and gastrointestinal symptoms 1, 3
Avoid citalopram doses exceeding 40 mg/day due to risk of QT prolongation 1
Avoid concomitant administration of SSRIs with MAOIs due to risk of serotonin syndrome 1

The British Journal of Psychiatry recommends using atypical antipsychotics at low doses to avoid extrapyramidal side effects and improve adherence 2
Start risperidone at 0.5 mg/day and titrate to initial target doses of 2 mg/day 2, 4, 5
For olanzapine, appropriate initial target doses are 7.5-10.0 mg/day 2, 4, 5
Increase doses only at widely spaced intervals (14-21 days after initial titration) if response is inadequate 2, 4
Generally limit maximum doses to 4-6 mg of haloperidol equivalent in first-episode psychosis 2, 4
If positive psychotic symptoms persist after trials of two first-line atypical antipsychotics, review reasons for treatment failure 2, 5

Include families in the assessment process and treatment planning 2, 5
Provide emotional support and practical advice to families, who are often in crisis at treatment initiation 2, 5
Consider more intensive psychoeducational interventions for families when there are frequent relapses or slow recovery 5

Avoid rapid dose escalation of antidepressants, which can increase anxiety and side effects 1
Do not exceed recommended maximum doses: citalopram >40 mg/day increases risk of QT prolongation 1, 6
Avoid abrupt discontinuation of SSRIs, particularly paroxetine, fluvoxamine, and sertraline, due to risk of discontinuation syndrome 1, 3
Do not use typical antipsychotics as first-line treatment for psychosis, as they are less well tolerated even at low doses 2, 5
Do not neglect monitoring for extrapyramidal side effects with antipsychotics, as these can significantly impact adherence 2, 5