Drug |
Chemical Effect |
Average Daily Dose |
Side Effects |
Indications |
Tricyclic Antidepressants (TCAs) |
Amitriptyline (tertiary amine) (Elavil) |
5HT, ±NE |
Children: 1-3 mg/kg/day Adolescents: 25-100 mg/day |
Cardiac arrhythmia, potentially lethal in overdose, anticholinergic side effects, orthostasis, sedation, GI intolerance, weight gain, sexual dysfunction. May increase risk of suicidal behavior. |
Not FDA-approved for use in children.
Historic uses: Insomnia, night terrors, enuresis, ADHD, chronic pain. |
Imipramine (tertiary amine) (Tofranil) |
Primary effects on NE |
For enuresis, initial dose usually 25 mg/day ages 6 years and older. May increase by 25 mg/day/week not to exceed 75 mg/day. |
As above. |
FDA-approved for treatment of enuresis for youth 6 yrs and older. |
Clomipramine (tertiary amine) (Anafranil) |
5HT (more potent than other TCAs) +NE |
Recommended starting dose is 25 mg/day. May increase 25 mg/day/wk up to 100-200 mg/day or 1.4 mg/pound whichever is smaller. Recommended max dose 200 mg/day. |
As above. |
FDA-approved for pediatric 0CD in youth 10 years and older. |
Doxepin (tertiary amine) (Sinequan) |
5HT, NE, H1, H2, M |
For sleep 10-25 mg 1 hour before bedtime. For depression start 10-25 mg/day. Increase slowly up to 50-100 mg/day. Usually more than 100 mg/day not needed in teens. |
As above.
Considered to have the least cardiotoxic potential of the TCAs. |
FDA-approved for depression in children over age 12. May also be helpful for pruritis, insomnia, and anxiety. |
Nortriptyline (secondary amine) (Pamelor) |
NE, ±5HT |
Suggested doses for
Children: 1-3 mg/kg/day in 3-4 divided doses.
Adolescents: 30-150 mg/day in 3-4 divided doses. |
Same as for amitriptyline, but anticholinergic effects less pronounced. |
Not FDA-approved for use in children. |
Desipramine (secondary amine) (Norpramin) |
Primary effects on NE |
For children 6-12 years old, the suggested dose ranges from 10 to 30 mg per day in divided doses. For adolescents, daily dosages range from 25 to 50 mg but may be increased up to 100 mg, if needed. |
Same as for imipramine, but anticholinergic effects less pronounced. Occasional insomnia. |
As above. |
While sudden death from arrhythmias is rare, concerns persist. |
Selective Serotonin Reuptake Inhibitors (SSRIs) |
Citalopram (Celexa) |
5HT reuptake inhibitors |
5-40 |
May increase risk of suicidal behavior. Activation and agitation.
Serotonin syndrome.
Weight gain.
Sexual side effects. |
Not FDA-approved in children, although widely used in pediatric populations. |
Escitalopram (Lexapro) |
|
2.5-20 |
|
FDA-approved for depression in children 12 years and older. |
Fluoxetine (Prozac) |
|
5-60 mg/day. |
|
FDA-approved for depression and OCD in youth 8 years and older. |
Sertraline (Zoloft) |
|
25-200 mg/day Divided dosing. |
|
FDA-approved for OCD in youth 6 years and older. Off-label used for depression and PTSD. |
Fluvoxamine (Luvox) |
|
25-200 mg/day divided dosing. |
|
FDA-approved for OCD in youth 8 years and older. |
Paroxetine (Paxil) |
|
No pediatric dosing recommendations. |
|
Not FDA-approved for children and not recommended for off-label use with pediatric populations. |
Atypical Antidepressants |
Bupropion (Wellbutrin) |
DA and NE reuptake inhibitor |
Starting dose is 37.5 mg increasing gradually (wait at least 3 days) to a maximum of 2-3 doses, no more than 150 mg/dose. |
Irritability, decreased appetite, and insomnia. Lowers seizure threshold especially for individuals with eating disorders and seizure disorders, and particularly with short acting dose preparation over 200 mg (adult data) May increase risk of suicidal behavior. |
Not FDA-approved in children, though used in pediatric populations for ADHD and depression. |
Atypical Antidepressants |
Bupropion (Wellbutrin SR) |
DA and NE reuptake inhibitor |
Usually dosed twice daily. Starting dose is 100 mg/day increasing gradually to a maximum of 100 mg bid in youth. Maximum recommended dose in adults 200 mg bid. |
As above. |
As above. |
Buproprion (Wellbutrin XL) |
DA and NE reuptake inhibitor |
Usually dosed once daily. Starting dose is 150 mg/day Usual maximum dose 300 mg/day in youth. Maximum dose in adults 450 mg/day. |
As above. |
As above. |
Venlafaxine (Effexor, Effexor XR) |
5HT and NE reuptake inhibitor |
No dosing information available for children. Start at lowest dose 25 mg once daily. Common maintenance dose in youth 25-100 mg/day. Usual maximum dose 225 mg/day for adults. |
GI intolerance, sexual dysfunction, activation, mania, sleep disturbance, hypertension. May increase risk of suicidal behavior. |
Not FDA-approved in children, though used in pediatric populations as third-line antidepressant for refractory depression. Consider use for ADHD. |
Mirtazapine (Remeron) |
5HT, NE reuptake inhibitor |
No dosing information available for children. Start at lowest dose possible 15 mg once daily. Maximum recommended dose in adults 45 mg/day. |
Somnolence, weight gain, rare agranulocytosis. May increase risk of suicidal behavior. Sedation is more common in low doses. |
Not FDA-approved in children, though used in pediatric populations as third-line antidepressant for refractory depression and to take advantage of its therapeutic and side effects of sedation. |
Trazodone (Desyrel) |
5HT 2A reuptake inhibitor |
Suggested initial dosing for insomnia
25 mg qhs, May increase in 25 mg increments to 100-150 mg qhs. |
Somnolence. Priapism is rare, more common in younger boys then in teens. |
Not FDA-approved in children, though commonly used in pediatric populations for insomnia. |
5HT, serotonin; NE, norepinephrine; DA, dopamine; H, histamine; M,muscarinic; SI, suicidal ideation; FDA, Food and Drug Administration; GI, gastrointestinal; 0CD, obsessive compulsive disorder; ADHD, attention-deficit hyperactivity disorder. |