| 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 |
| | Risperidone (Risperdal) | Initial dosage: 0.25 mg per day at bedtime; maximum: 2 to 3 mg per day, usually twice daily in divided doses | Comments: current research supports use of low dosages; extrapyramidal symptoms may occur at 2 mg per day. |
| | Olanzapine (Zyprexa) | Initial dosage: 2.5 mg per day at bedtime; maximum: 10 mg per day, usually twice daily in divided doses | Comments: generally well tolerated |
| | Quetiapine (Seroquel) | Initial dosage: 12.5 mg twice daily; maximum: 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 in patients who cannot tolerate or do not respond to atypical antipsychotic agents |
| General cautions: current research suggests that these drugs should 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. |
| | 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), perphenazine (Trilafon), loxapine (Loxitane) | Dosage: varies by agent | Comments: agents with “in-between” side effect profile |
| Mood-stabilizing (antiagitation) 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 per day; maximum: 200 to 400 mg per 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 to 8 mcg per 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 to 90 mcg per 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 agitation 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: 20 mg three 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 (e.g., sedation versus activation); a full therapeutic trial requires at least 4 to 8 weeks; as a rule, dosage is increased using increments of initial dose every 5 to 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 to 14 days limits withdrawal symptoms. NOTE: Patients with depression and psychosis require concomitant antipsychotic medication. |
| Tricyclic antidepressant agents |
| | Desipramine (Norpramin) | Initial dosage: 10 to 25 mg in the morning; maximum: 150 mg in the morning | Comments: tends to be activating (i.e., reduces apathy); lower risk for cardiotoxic, hypotensive, and anticholinergic effects; may cause tachycardia; blood levels may be helpful- |
| | Nortriptyline (Pamelor) desipramine, | Initial dosage: 10 mg at bedtime; anticipated dosage range: 10 to 40 mg per day (given twice daily) | Comments: tolerance profile is similar to that for but nortriptyline tends to be more sedating; may be useful in patients with agitated depression and insomnia; therapeutic blood level “window” of 50 to 150 ng per mL (190 to 570 nmol per L) |
| Heterocyclic and noncyclic antidepressant agents |
| | Nefazodone (Serzone) | Initial dosage: 50 mg twice daily; maximum: 150 to 300 mg twice daily | Comments: effective, especially in patients with associated anxiety; reduce dose of coadministered alprazolam (Xanax) or triazolam by 50%; monitor for hepatotoxicity. |
| | Bupropion (Wellbutrin) | Initial dosage: 37.5 mg every morning, then increase by 37.5 every 3 days; maximum: 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 3 p.m. |
| | Mirtazapine (Remeron) | Initial dosage: 7.5 mg at bedtime; maximum: 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 can include sweating, tremors, nervousness, insomnia or somnolence, dizziness, and various gastrointestinal and sexual disturbances. |
| | Fluoxetine (Prozac) | Initial dosage: 10 mg every other morning; maximum: 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 per day; maximum: 40 mg per day (morning or evening) | Comments: less activating but more anticholinergic than other SSRIs |
| | Sertraline (Zoloft) | Initial dosage: 25 to 50 mg per day; maximum: 200 mg per 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 per day; maximum: 40 mg per day | Comments: well tolerated; some patients experience nausea and sleep disturbances. |
| | Fluvoxamine (Luvox) | Initial dosage: 50 mg twice daily; maximum: 150 mg twice daily | Comments: exercise caution when using fluvoxamine with alprazolam or triazolam. |
| Phenethylamine |
| | Venlafaxine (Effexor) | Initial dosage: 37.5 mg twice daily; maximum: 225 mg per day in divided doses | Comments: highly potent; also inhibits norepinephrine reuptake |
| Lithium |
| Recommended uses: for anticycling; can also be used to augment antidepressant drugs |
| General cautions: at higher lithium dosages, elderly patients are prone to develop neurotoxicity. |
| | Lithium | Initial dosage: 150 mg per day | Comments: blood levels of 0.2 to 0.6 mEq per L (0.2 to0.6 mmol per L) are generally adequate and are usuallyachieved with dosage of 150 to 300 mg per day. |
| Electroconvulsive therapy |
| Recommended uses: may be required in patients who are at risk of injuring or starving themselves, patients who are severely psychotic, and patients who cannot tolerate or do not respond to antide pressants |