Table 13.6-5. Dosing of common first-line medications shown to be effective in treating major depression (based on British National Formulary [BNF] 72)

Medication

Starting dose (mg/d)

Usual dose (mg/d)

Selective serotonin reuptake inhibitors

Citalopram

20

20-40

Escitalopram

10

10-20

Fluoxetine

20

20-60

Paroxetine

20

20-50

Sertraline

50

50-200

Serotonin-norepinephrine reuptake inhibitors

Venlafaxine, immediate release

75

75-375

Venlafaxine, extended release

75

75-375

Duloxetine

60

60-120

Norepinephrine-serotonin modulator

Mirtazapine

15

15-45

Dopamine-norepinephrine reuptake inhibitor

Bupropion, immediate release

150

300-450

Bupropion, sustained release

150

300-400

Bupropion, extended release

150

300-450

For some of these medications (such as tricyclic antidepressants), the upper dosing limit reflects risk of toxicity or need for plasma level assessment, whereas others (such as selective serotonin reuptake inhibitors) can be used safely at higher doses.

Elderly patients, patients with anxiety disorders, patients with liver disease or other major medical comorbidities should receive a lower starting dose.

Starting doses should be increased gradually until therapeutic dose is reached or the patient achieves remission.