Table

NEWJournalMN660_Unit8_Journal2.docx

Table of Contents NU660 Psychopharmacology and Health promotion Neurotransmitter Chart (Journal 2) Antipsychotics Chart and Mood Stabilizers Chart (Journal 4) Antidepressants and Anxiolytics (Journal 6) Substance Use Resources (Journal 8) Additional Resources List Journal # 2

Neurotransmitters Chart
	Function (Excitatory or Inhibitory)	Locations	Receptors	Effects of Deficient	Effects of Surplus	Agonist Drug	Antagonist Drug
Acetylcholine	Acetylcholine has both excitatory and inhibitory properties, it has the ability to both accelerate and decelerate nerve impulses. Its primary function in the central nervous system is excitatory. It affects learning, memory, arousal, and neuroplasticity. It also contributes to the brain's reward system, helps people maintain concentration, and activates sensory processes as they wake up. Acetylcholine plays a role in sustaining rapid eye movement (REM) sleep, which is the dream-inducing phase of sleep. It facilitates the contraction of cardiac, skeletal, and smooth muscles within the peripheral nervous system. Acetylcholine imbalances may have a role in the development of myasthenia gravis, an autoimmune disease characterized by fatigue and weak muscles.	Acetylcholine is found in the Central Nervous System (CNS), the human brain, spinal cord, and in the peripheral nervous system.	Acetylcholine binds to two different receptors called nicotinic and muscarinic receptors.	Alzheimer’s Learning disorders, Confusion Memory Loss	Muscle spasms Muscular Weakness Paralysis Muscular Fasciculation	Nicotine, Cevimeline, Carbamoylcholine, Bethanechol, Pilocarpine, Varenicline, Arecoline, Lobeline, and GTS-21	Trospium, Darifenacin, Atropine, Tolterodine, Oxybutynin, Solifenacin, Flavoxate, Fesoterodine, Propiverine, and Oxyphenonium
Dopamine	Dopamine is a (inhibitory) neurotransmitter made in your brain. In addition to being a "reward center," it is involved in a variety of bodily processes, such as memory, locomotion, motivation, mood, attention, and more. Diseases like Parkinson's disease, restless legs syndrome, and attention deficit hyperactivity disorder (ADHD) are linked to either high or low dopamine levels.	Hypothalamus and lower levels located in the basal ganglia. Central Nervous System Substantia Nigra Ventral Tegmental Area,	Central Nervous System hippocampal dentate gyrus and subventricular zone. D1, D2, D3, D4, and D5	Parkinson’s Disease	Schizophrenia and drug addictions	Ropinirole, Pramipexole, Apomorphine, Pergolide, Bromocriptine, Rotigotine, Piribedil, Dihydroergocryptine, Fenoldopam, and Cabergoline	Ziprasidone, Thiethylperazine, Sulpiride, Loxapine, Remoxipride, Promazine, Prochlorperazine, Droperidol, Chlorpromazine, and Haloperidol
Endorphins	(Inhibitory) Your body releases endorphins, which are chemicals (hormones), in response to stress or pain. They are also released during enjoyable activities including eating, exercising, getting a massage, and having sex. Endorphins assist in pain relief, stress reduction, and wellbeing enhancement. The brain regions of the pituitary gland and hypothalamus are where endorphins are produced. One kind of neurotransmitter, or messenger, in your body is endorphins. They convey messages throughout your nervous system and bind to the opioid receptors in your brain, which are the reward centers.	Pituitary gland Hypothalamus B-Endorphins-Central Nervous System	Opioids receptors Pre and Post Nerve Synaptic.	Your body may create less endorphins than it should, which could put you at risk for certain illnesses or symptoms like more aches and pains, worry and despair, irritability, addiction, and difficulty falling asleep.	Depression, low sex drive, depression, extreme fatigue, infertility, and low testosterone.	Opioids	Naloxone,
GABA	(Inhibitory) One amino acid that exists naturally is gamma-aminobutyric acid (GABA). As a neurotransmitter, GABA sends messages from one neuron to another throughout your nervous system. As an inhibitory neurotransmitter, GABA in particular inhibits the transmission of other signals and regulates the pace at which information passes through the nervous system.	Hippocampus, Thalamus, Basal Ganglia, hypothalamus, brainstem.	GABAa GABAb GABAc Globus pallidus	Anxiety, seizures, tremors, and insomnia.	Sleeping and eating disorders	Baclofen, Zolpidem, Progabide, AZD 3355, Tramiprosate, Gaboxadol, Adipiplon, Zolpidem ER, Arbaclofen, eszopiclone, Sonata, Placarbil, Lesogaberan, and Muscimol	Clozapine, Picrotoxin, SGS-742, Bicuculline, benzodiazepine, Metrazol, securinine, and Pentetrazol
Glutamate	Glutamate is an excitatory neurotransmitter that is found in the central nervous system and has a variety of receptor types. The extracellular space relies on glutamate metabolism to maintain levels at appropriate levels. It is crucial for memory, thought, and mood management as a result.	Central Nervous System Synaptic vesicles in nerve terminals	Brain Spinal Cord in neuron Glia NMDA, AMPA, kainite	Mental exhaustion, insomnia, concentration problems.	Seizures, anxiety disorders, autistic spectrum disorder, neurodegenerative disease, amyotrophic lateral sclerosis.	AMPA, Glutamic acid, Ibotenic acid Kainic acid Quisqualic acid	Dextromethorphan, Amantadine, Ketamine, Orphenadrine, Meperidine, Agmatine, Ifenprodil, Tenocyclidine, Haloperidol
Glycine	(Inhibitory) Numerous significant metabolites, including glutathione, creatine, porphyrins, and purines, are precursors to glycine. In addition to its multiple functions as an antioxidant, anti-inflammatory, cryoprotective, and immunomodulatory in peripheral and neurological tissues, glycine is a neurotransmitter in the central nervous system.	Central Nervous Brain Spinal Cord	Central Nervous System Vertebrates Glyr Adult Spinal cord Brainstem	Glycine encephalopathy	Hyperglycinemia Anxiety	B-Alanine, D-Alanine, D-Serine, Hypotaurine, L-Alanine, L-Proline, L-Proline, L-Serine, Milacemide, Quisqualamine, Sarcosine, Taurine, and Hypotaurine.	Brucine, Strychnine, Tutin, Bicuculline, Picrotoxin, Pitrazepin, and Thiocolchicoside.
Norepinephrine	Norepinephrine's (excitatory) main purpose is to prepare the body and brain for action. The release of norepinephrine is greatest during the fight-or-flight reaction, which occurs in response to stress or danger, and it peaks during wakefulness. Norepinephrine is released at its lowest during sleep. Norepinephrine is a neurotransmitter that raises arousal and alertness, encourages vigilance, improves memory formation and retrieval, and concentrates attention. It also raises anxiety and restlessness. Norepinephrine affects the rest of the body in the following ways: it raises blood pressure and heart rate, causes glucose to be released from energy stores, increases blood flow to skeletal muscle, decreases blood flow to the gastrointestinal tract, and inhibits gastrointestinal motility and bladder emptying.	Locus coeruleus Brain Spinal Cord	Alpha 1 Alpha 2 Beta receptors	Depression, Mood disorders	Anxiety Increased Heart rate Increase blood pressure. Irritability Hyperactivity Stress	Ephrine, Midodrine, Droxidopa Pseudoephedrine Isoetharine, and Phenylephrine	Lopressor, Catapres, Minipress, Sulpiride, Nisoxetine
Serotonin	Serotonin is a (inhibitory) neurotransmitter that moves through your body and between brain cells to transmit messages. Body processes like mood, sleep, digestion, nausea, wound healing, bone health, blood coagulation, and sexual desire are all significantly influenced by serotonin.	Central Nervous System Gastrointestinal Tract	5-HT1 5-HT2 5-HT4 5-HT6 5-HT7	Depression, Attention deficit hyperactivity disorder, and post stress disorder.	Altered mental status, neuromuscular hyperactivity, autonomic hyperactivity, and Autism.	Eletriptan, Zolmitriptan, Lisuride, Sumatriptan, Ergotamine, Almotriptan, Naratriptan, Rizatriptan, and Frovatriptan,	Alosetron, Ketanserin, Ziprasidone, Clozapine, Risperidone, Grainsetron, Dolasetron, and Cyproheptadine

Notes:

Journal # 4

Antipsychotics

First Generation

Side Effects (L=Low, M=Moderate, H=High)

Generic Name

Trade Name

Route(s) of Administration

LAI option?

Starting Dose

Half Life

Indications (s/sx & diagnosis)

MOA (neurotransmitter effects)

EPS

Hyperlipidemia

T2DM

Weight Gain

Cognitive Issue

Other SE

Costs

Chlorpromazine

Thorazine

IM/IV/PO/Suppository

No LAI Option.

Mania/Psychosis/Schizophrenia-500 mg orally per day.

Parenteral 25 mg IV once, repeated in 1 hour if necessary.

Outpatients: 10 mg by mouth 3 to 4 times a day.

8-33 hours.

Schizophrenia

Bipolar I acute manic type of manic-depressive illness

Acute agitation marked by explosive hyperexcitable behavior.

Adjunct treatment of serotonin syndrome (off-label).

Chlorpromazine blocks Dopamine D2 receptors in Mesolimbic dopamine pathways in the brain.

Orthostatic Hypotension

Dry mouth

Amenorrhea

Galactorrhea

$ 138.71 (10 mg tablets-100 count) $132.00 (25mg supply of 50 tablets), $201.90 (50 mg tablets for 100 tablets), $377.95 (100 mg tablets-100 tablets), $365.54 (200 mg tablets for 20 tablets), $746.16 (25mg/mL), 545.00 (30mg/mL), $2,304.50 (100mg/mL)

Fluphenazine

Prolixin

IM/PO

Fluphenazine Decanoate

Psychosis – 2.5 to 10 mg orally in divided doses every 6 to 8 hours.

Fluphenazine Decanoate (Parenteral) 12.5 mg to 25 mg deep IM injection.

Fluphenazine HCL for injection – 2.5 to 10 mg IM, given as divided doses every 6 hours.

Geriatric Dose-1 to 2.5 mg orally, given in divided doses every 6 to 8 hours.

(oral) 15 hours.

(IM) 6.8-9.6 days.

Psychosis in patients with schizophrenia. There is a long acting fluphenazine decanoate used for maintenance therapy for chronic schizophrenia and related psychotic disorders in patients who do not tolerate oral formulation.

Fluphenazine blocks postsynaptic mesolimbic dopaminergic D1 and D2 receptors in the central nervous system.

Drowsiness

Lethargy

Dizziness

Dry Mouth

$205.41 (2.5 mg/mL for 10 mL), $78.66 (decanoate 25mg/mL for 5 mL), $329.54 (5mg/mL for 120 mL), Oral elixir $42.13 for 60 mL, Oral tablets $23.37 (1mg for 50 tablets), $60.50 for (2.5 mg 50 tablets).

Haloperidol

Haldol

IM/IV/PO

Haldol Decanoate

Psychosis-0.5 to 2 mg by mouth 2 to 3 times a day.

Haloperidol Lactate for injection- 2 to 5 mg IM every 4 to 8 hours.

Schizophrenia – 0.5 mg to 2 mg by mouth 2 to 3 times a day.

Haloperidol Decanoate for injection- 100 mg.

(Decanoate) 3 weeks

(Oral) 12-38 hours.

Manages positive symptoms of schizophrenia, including hallucination and delusions.

Haloperidol competitively blocks post-synaptic dopamine (D2) receptors in the brain, eliminating dopamine neurotransmission and leading to the relief of delusions and hallucinations that are commonly associated with psychosis.

Dry Mouth

Blurred Vision

Agitation

Headache

Fever

Muscle Stiffness

Injectable Solution-5 mg/mL from $19.66 for 10 mL. Intramuscular Solution-decanoate 50mg/mL $17.50 for 1mL, decanoate 100mg/mL from $37.04 for 1 mL. Oral Concentrate-2mg/mL from $17.14 for 15 mL. Oral Tablet-0.5mg from $37.17 for 100 tablets, 1mg from $41.63 for 100 tablets, 2mg from $49.50 for 100 tablets, 5mg from $42.25 for 100 tablets, 10 mg from $54.13 for 100 tablets, and 20 mg from $88.53 for 30 tablets.

Loxapine

Loxitane

IM/PO/Inhalatory

No LAI Option.

Schizophrenia-10 mg by mouth twice a day.

(Oral) 4 hours (IM) 12 hours.

Schizophrenia

Loxapine works by balancing the levels of dopamine and serotonin in the brain, which regulates mood, behaviors, and thoughts.

Tachycardia

Convulsions

Constipation

Severe Nervous System Reaction

Oral Capsule-5mg from $58.68 for 60 capsules, 10 mg from $60.89 for 60 capsules, 25 mg from $132.81 for 100 capsules, and 50 mg from $189.53 for 100 capsules.

Perphenazine

Trilafon

No LAI Option.

Psychosis-4 to 8 mg orally 3 times a day, with a dose reduction to the minimum effective dose as soon as possible.

Hospitalized Patients- 8to 16 mg orally 2 to 4 times a day.

9.5 hours

Schizophrenia

Perphenazine is piperazine phenothiazide derivative which acts by postsynaptic inhibition of dopamine receptors.

Bradycardia

Jaundice

Low white blood cell count

Constipation

$39.41 (2mg tablets 100 count), $43.93 (4 mg for 100 tablets), $56.40 (8mg tablets-100 count), $88.12 (16 mg tablets for 100 count).

Second Generation

Aripiprazole

Abilify

PO/IM

Aristada

Schizophrenia- 10 mg or 15 mg by mouth once a day.

Parenteral Formulations- 400 mg IM once, continue aripiprazole IR 10 to 20 mg orally for 14 days.

Bipolar Disorder-15 mg by mouth once a day.

Adjunctive Therapy-10 mg to 15 mg by mouth once a day.

Parenteral Formulation- 400 mg IM once; continue aripiprazole IR 10 to 20 mg orally once a day for 14 days.

75 hours (Aripiprazole)

94 hours (major metabolite dehydro-aripiprazole)

Symptomatic management of psychosis in patients with schizophrenia and monotherapy or adjunctive therapy for acute manic episodes associated with bipolar disorder. The oral tablet and solutions are used to treat autistic spectrum disorder. Aripiprazole can also serve as an adjunctive treatment for major depressive disorder and Tourette syndrome.

Aripiprazole is a partial agonist at D2 receptors. It may act as an antipsychotic by lowering dopaminergic neurotransmission in the mesolimbic pathway. Enhancing dopaminergic activity in the mesocortical pathway.

Oral Solution $275.12 for 150mL, Oral tablets-$11.80 for 2mg tablets-30 tablets, $12.25 5mg tablets- for 30 tablets, $13.17 for 10 mg-30 tablets. Oral disintegrating- $712.48 (10 mg for 30 tablets), $760.97 (15 mg for 30 tablets).

Asenapine

Saphris

SL/Transdermal

No LAI Option.

Schizophrenia – 5 mg sublingually 2 times a day.

Bipolar Disorder – 10 mg sublingually 2 times a day.

Adjunctive therapy – 5 mg sublingually 2 times a day.

Bipolar (Pediatric) 2.5 mg sublingually 2 times a day.

24 hours (range of 13,4-39.2 hours).

Atypical antipsychotic for treatment of schizophrenia and acute mania associated with bipolar disorder. Asenapine also belongs to the dibenzo-oxepino pyrrole class. It is also for severe post-traumatic stress disorder nightmares in soldiers as an off-label use.

Asenapine is an atypical antipsychotic multireceptor neuroleptic drug which shows strong 5HT2A (serotonin) and D2 (Dopamine) receptor antagonism.

Uncontrollable switching

Abdominal pain

Fever

Heartburn

Hyperventilation

Sublingual - $1,111.35 (2.5 mg for 60 tablets), $239.00 (5mg for 60 tablets), $ 239.00 (10 mg for 60 tablets). Transdermal – 30 quantity $47.20 per unit.

Clozapine

Clozaril

No LAI Option.

Schizophrenia – 12.5 mg by mouth once or twice a day.

After reaching a steady state with 100 mg twice daily dosage, the mean elimination half-life of clozapine was 12 hours (range: 4 to 66 hours), whereas the mean elimination half-life following a single 75 mg dose was 8 hours (range: 4 to 12 hours).

Patients with severe schizophrenia who do not react well to normal antipsychotic medication should be treated with clozapine. Clozapine should only be used in individuals who have not responded sufficiently to normal antipsychotic medication due to the risks of severe neutropenia and seizure. In individuals with schizophrenia or schizoaffective disorder who are assessed to be chronically at risk of re-experiencing suicide behavior, clozapine is also recommended to lessen the likelihood of repeated suicidal behavior based on their history and current clinical condition.

The mechanism by which clozapine exerts its effects involves the blocking of 5-HT2A/5-HT2C serotonin receptors and the D1-4 dopamine receptors, with the highest affinity for the D4 dopamine receptor.

Constipation

Dizziness

Headache

Drooling

Vision Problems

$ 46.15 (25mg – 100 count), $62.30 (50 mg -100 count), $105.07 (100 mg-100 tablets), $218.51 (200 mg -100 count). Oral tablet disintegrating: $198.84 (12.5 mg -100 count), $76.69 (25 mg -48 count), $214.48 100mg-40 count), $854.73 150mg-48 count), $1,136.43 (200 mg for 48 tablets).

Iloperidone

Fanapt

No LAI Option.

1 mg by mouth twice a day.

Iloperidone, P88, and P95 have been found to have mean elimination half-lives of 18, 26, and 23 hours in CYP2D6 extensive metabolizers (EM) and 33, 37, and 31 hours in poor metabolizers (PM).

An atypical antipsychotic medication called iloperidone is used to treat adult schizophrenia acutely.

Iloperidone is a dopamine D2 and 5-HT2A receptor antagonist and acts as a neuroleptic agent.

Body Aches

Chills

Cold Sweats

Cough

Drooling

Dizziness

Ear Congestion

Oral Tablet-1mg-2mg-4mg-6mg from $255.74 for 8 tablets, 1mg from $1856.08, 2mg from $1856.08 for 60 tablets, 4mg from $1856.08 for 60 tablets, 6mg and 8mg from $2281.60, 10 mg and 12 mg from $3648.16 for 60 tablets.

Olanzapine

Zyprexa

IM/PO

Zyprexa Relprevv

Bipolar Disorder – 10 mg to 15 mg orally once a day.

Adjunctive Treatment – 10 mg orally once a day.

Depressive Episodes with Bipolar I Disorder – 5 mg by mouth once a day.

Schizophrenia – 5mg to 10 mg orally once a day.

Parenteral – 210 mg IM every 2 weeks or 405 mg IM every 4 weeks for the first 8 weeks.

Depression – 5 mg orally once a day.

Agitated State – 10 mg IM once.

Geriatric – Agitated State- 5 mg IM once.

Pediatric dose for Schizophrenia- 2.5 mg to 5 mg orally once a day.

Olanzapine has a half-life that ranges from 21 to 54 hours, with a half-life average of 30 hours.

Zyprexa is used to treat psychotic illnesses in adults and children who are at least 13 years old, including schizophrenia and bipolar disorder (manic depression).

In addition, adults and children with bipolar I disorder who are at least ten years old and experience depressive episodes are treated with Zyprexa in addition to fluoxetine (Prozac).

Olanazapine exerts its action primarily on dopamine and serotonin receptors. It works on dopamine D2 receptors in the mesolimbic pathway as an antagonist, blocking dopamine from potential action at the post synaptic receptor.

Impaired Vision

Shuffling Gait

Slurred Vision

Tinging of feet

Intramuscular-10 mg from $62.42 for 1 powder injection. Oral Tablet-2.5 mg from $431,23 for 30 tablets, 5 mg from $507.04 for 30 tablets, 7.5 mg from $614.75 for 30 tablets, 10 mg from $759.13 for 30 tablets, 15 mg from $1133.95 for 30 tablets, and 20 mg from $1508.76 for 30 tablets.

Paliperidone

Invega

IM/PO

Invega Sustena

Invega Palmitate

Invega Trinza

Schizophrenia – 6 mg orally once a day.

Paliperidone Palmitate – 234 mg IM on day 1 followed by 156 mg IM once a week.

Paliperidone (base) – 150 mg IM on day 1 followed by 100 mg IM one week later.

Schizoaffective Disorder – 6 mg orally once a day.

Pediatric (Schizophrenia) 3 mg orally once a day.

Paliperidone has a half-life of roughly 23 hours for terminal elimination.

Paliperidone is indicated for the treatment of adults and adolescent with schizophrenia and in the treatment of schizoaffective disorder in combination with antidepressants or mood stabilizers. Paliperidone is also given as IM every three months for the treatment of schizophrenia.

The mechanism of action of paliperidone, as with other drugs having efficacy in schizophrenia, is unknown, but it has been proposed that the drug’s therapeutic activity in schizophrenia is mediated through a combination of central dopamine Type 2 (D2) and serotonin Type 2 (5HT2A) receptor antagonism.

Difficulty Speaking

Drooling

Chest Pain

Stiffness of Limbs

Loss of Balance Control

Oral Tablet, Extended Release-3 mg and 6 mg from $396.85 for 30 tablets, 9 mg from $590.53 for 30 tablets. IM Suspension-273 mg/0.88 from $3534.96 for 0.88 milliliters. 410 mg/1.32 mL from $5297.78 for 1.32 milliliters, 546 mg/1.75 mL from $7060.82 for 1.75 milliliters, and 819 mg/2.63 mL from $10,586.24 for 2.63 milliliters.

Quetiapine

Seroquel

No LAI Option.

Day 1: 25 mg orally 2 times a day Days 2 and 3: Increase in 25 to 50 mg increments, given in divided doses 2 or 3 times daily. Day 4: 300 to 400 mg orally per day, given in divided doses. Extended Release - Day 1: 300 mg orally once a day. Titration regimen: Increase in increments of up to 300 mg/day at intervals as frequently as 1 day. Maintenance dose: 400 to 800 mg orally once a day. Maximum dose: 800 mg/day MAINTENANCE MONOTHERAPY: Maintenance dose: 400 to 800 mg orally once a day. Maximum dose: 800 mg/day. Depression Day 1: 50 mg orally once a day. Day 2 50 mg orally once a day. Day 3: 150 mg orally once a day. Maintenance dose: 150 mg to 300 mg orally once a day. Maximum dose: 300 mg/day.

Questiapine typically has a terminal half-life of 6-7 hours.

Seroquel is used to treat schizophrenia in adults and children who are at least 13 yrs. old. Seroquel is also used alone or with lithium to treat episodes of mania (frenzied, abnormally excited, or irritated mood or depression in patients with bipolar disorder (manic depressive).

Seroquel works by balancing the levels of dopamine and serotonin in your brain, hormones that help regulate mood, behaviors, and thoughts.

Oral Tablet-25 mg from $418.60 for 100 tablets, 50 mg from $681.75, 100 mg from $711.54 for 100 tablets, 200 mg tablets from $1333.91 for 100 tablets, 300 mg from $1051.43 for 60 tablets, and 400 mg from $2050.32 for 100 tablets.

Risperidone

Risperdal

Risperdal Consta

Risperdal subcutaneous

Uzedy

Schizophrenia- 2 mg orally per day.

Long-acting IM injection: 25 mg IM every 2 weeks.

Bipolar Disorder: 2 to 3 mg orally per day.

Long-acting IM injection: 25 mg IM every 2 weeks.

Geriatric-0.5 mg orally twice a day.

Long-acting IM Injection: 25 mg IM every 2 weeks.

Pediatrics (Schizophrenia) 0.5 mg orally once a day.

Bipolar – 0.5 mg orally once a day.

3 hours for those with high metabolisms and up to 20 hours for those with low metabolisms.

Risperidone is indicated for the treatment of schizophrenia and irritability associated with autistic disorder. It is also indicated as monotherapy, or adjunctly with lithium or valproic acid, for the treatment of acute mania or mixed episodes associate with bipolar disorder. It is also used for management of aggression of psychotic symptoms in patients with dementia and Alzheimer’s. It is used off-label for a number of conditions such as antidepressants in treatment resistant depression.

Risperidone decreases dopaminergic and serotonergic pathway activity in the brain, therefore decreasing symptoms of schizophrenia and mood disorders. Risperidone has a high binding affinity for serotonergic 5-HT2A receptors when compared to dopaminergic D2 receptors in the brain.

Oral Solution-1mg /mL from $182.46 for 30 mL. Oral Tablet-0.5 mg from $300.72 for 60 tablets. 1mg from $319.12 for 60 tablets, 2 mg from $526.93 for 60 tablets, 3 mg from $617.25 for 60 tablets, and 4 mg from $825.79 for 60 tablets.

Ziprasidone

Geodon

PO/IM

No LAI Option.

Schizophrenia-20 mg by mouth twice daily.

Bipolar 1 Disorder – 40 mg twice a day with food.

IM dosing-10 mg to 20 mg as required (maximum dose) 40 mg.

The half-life of ziprasidone is 6-7 hours.

Acute treatment of manic or mixed episodes of bipolar disorder, maintenance (long-term) treatment of bipolar disorder when used with valproate, used in acute treatment of agitation in schizophrenia.

Ziprasidone binds to serotonin 2A (5-HT2A) and dopamine D2 receptors in a similar fashion to other atypical antipsychotic, however, one key difference is that ziprasidone has a higher 5-HT2A/D2 receptor affinity ratio when compared to others.

Drowsiness

Dizziness

Weakness

Nausea

Vomiting

Intramuscular Powder for Injection 20 mg from $212.58 for 10 powders for injection. Oral Capsule (20 mg from $66.87 for 20 capsule). 40 mg from $58.44 for 20 capsules. 60 mg from $65.08 for 20 capsules and 80 mg from $64.38 for 20 capsules.

Pimavanserin

Nuplazid

No LAI Option.

Nuplazid dose is 34 mg taken orally once daily, without titration.

Pimavanserin's and its active metabolite AC-279's estimated typical plasma half-lives are 57 hours and 200 hours, respectively.

Pimavanserin is indicated for the treatment of hallucinations and delusion associated with Parkinson’s disease psychosis.

Pimavanserin is a combination of inverse agonist and antagonist activity at the serotonin 2A receptors (5-HT2A) and, to a lesser extent at the HT2C receptors.

Bloating or swelling of the face, arms, hands, lower legs, or feet.

Confusion

Clumsiness

Sleepiness

Oral Capsule-34 mg from $5269.24 and oral capsules (10 mg from $5269.24 for 30 tablets).

Cariprazine

Vraylar

No LAI Option.

Schizophrenia – 1.5 mg once daily.

Manic or Mixed Episodes associated with bipolar disorder- 1.5 mg once daily and should be increased to 3 mg daily on day 2.

Adjunctive therapy – 1.5 mg once daily.

The half-lives of capricrazine and its active metabolites are very lengthy. The terminal half-lives of the following compounds: 31.6 to 68.4, 29.7 to 37.5, and 314 to 446 hours for cariprazine, DCAR, and DDCAR, respectively. The functional half-life of all active moieties, or the effective half-life, was roughly one week when measured from time to steady state.

Cariprazine is indicated to treat along with antidepressant medicines to treat major depressive disorder. Also used for short term (acute) treatment of manic or mixed episodes that with bipolar 1 disorder. Cariprazine is also used to treat depressive episodes that happens with bipolar 1 (bipolar depression).

Oral Capsule-1.5 mg-3 mg from $347.99 for 7 capsules, 1.5 mg, 3 mg from $976.63 for 20 capsules, and 4.5mg, 6 mg from $1460.18 for 30 capsules.

Lurasidone hcl

Latuda

No LAI Option.

Schizophrenia – 40 mg orally once a day.

Bipolar Disorder – 20 mg orally once a day.

Pediatric (bipolar disorder) 20 mg orally once a day.

Pediatric (schizophrenia) 40 mg orally once a day.

40 mg dose=18 hours 120mg -160mg dose = 29-37 hours.

Lurasidone is indicated for the treatment of schizophrenia in patients greater than 13 years old. It is also indicated as a monotherapy for treatment of bipolar depression in patients greater than 10 years old or in combo with lithium or valproate for the treatment of bipolar depression in adults.

Lurasidone is a D2 and 5-HT2A (mixed serotonin and dopamine activity) to improve cognition. It is thought that antagonism of serotonin receptors can improve negative symptoms of psychoses and reduce the extrapyramidal side effects that are often associated with typical antipsychotics.

Oral Tablet-20 mg, 40 mg, 60 mg, 80 mg & 120 mg from $1503.39 for 30 tablets.

Brexipiprazole

Rexulti

No LAI Option.

Major Depressive Disorder: 0.5 mg to 1mg daily.

Schizophrenia: 1 mg daily on days 1 to 4. Titrate to 2 mg once daily on day 5 through day 7.

Brexpiprazole and its main metabolite, DM-3411, had terminal elimination half-lives of 91 hours and 86 hours, respectively, following numerous once-daily doses.

Brexipiprazole is indicated for adjunctive treatment of major depressive disorder in adults. This drug is also used to treat schizophrenia in adults and children 13 years or older.

Chills

Cold sweats

Fainting

Dizziness

Confusion

Oral Tablets-0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg from $1503.75 for 30 tablets.

Lumateperone

Caplyta

No LAI Option.

Caplyta is 42 mg orally once daily with or without food. Dose titration is not required.

13-18 hours.

Adult schizophrenia is one of the conditions for which caplyta is suggested. bouts of depression linked to adult bipolar I or II disorder (bipolar depression), both as a monotherapy and as an adjuvant treatment with valproate or lithium.

Stroke, Tardive dyskinesia

Oral Capsule-10.5mg, 21mg, & 42mg from $1661.83 for 30 capsules.

Mood Stabilizers

Generic Name

Trade Name

Route(s) of Administration

LAI option?

Starting Dose

Half Life

Indications (s/sx & diagnosis)

MOA (neurotransmitter effects)

EPS

Hyperlipidemia

T2DM

Weight Gain

Cognitive Issue

Other SE

Costs

Lithium

Eskalith

No LAI Option.

Mania: 600 mg orally 2 to 3 times a day.

Bipolar: 600 mg orally 2 to 3 times a day.

Pediatric (Mania): 600 mg orally 2 to 3 times a day.

Pediatric (Bipolar) 600 mg orally 2 to 3 times a day.

18-30 hours,

Lower absorption on empty stomach.

Mood stabilizer and commonly prescribed for manic episode in bipolar disorder as well as maintenance therapy of bipolar disorder in patients with a history of a manic episode. Lithium is also prescribed for major depressive disorder as an adjunct therapy, bipolar disorder.

Lithium enhances inhibitory neurotransmission by down regulating the NMDA receptor and inhibiting the myoinositol second messenger system directly.

Confusion

Fainting

Frequent urination

Increased thirst

Oral Capsule $14.86 for 100 capsules, $14.72 (300 mg – 100 capsules), $ 19.70 (600 mg for 100 capsules). Oral Syrup $285.07 300mg/5mL for 500 mL), Oral tablet $ 18.00 (300 mg for 100 tablets, Oral tablet ER $ 13.14 for 30 tablets), $13.18 (450 mg for 30 tablets).

Valproate

Depakote ER

No LAI Option.

Epilepsy: 10 to 15mg/kg/day orally; doses greater than 250 mg/day should be given in divided dose.

Epilepsy: 10 to 15mg/kg/day orally; doses greater than 250 mg should be given in divided doses. Parenteral: 60 minutes IV infusion.

9-16 hours

Manic episodes associated with bipolar disorder, impulsivity, agitation, aggression, and seizures.

Valproate is known to inhibit succinic semialdehyde dehydrogenase. This inhibition results in an increase in succinic semialdehyde which acts as an inhibitor of GABA transaminase ultimately reducing GABA metabolism and increasing GABAergic neurotransmission.

Shivering

Sore throat

Sweating

Muscle aches

diarrhea

Oral tablet, Extended Release $ 360.25 (250 mg for 100 tablets), $626.49 (500 mg for 100 tablets).

Lurasidone

Latuda

No LAI Option.

Schizophrenia – 40 mg orally once a day.

Bipolar Disorder – 20 mg orally once a day.

Pediatric (bipolar disorder) 20 mg orally once a day.

Pediatric (schizophrenia) 40 mg orally once a day.

40 mg dose=18 hours 120mg -160mg dose = 29-37 hours.

Schizophrenia, FDA expanded the usage to include pediatric patients 10 to 17 years of age to treat major depressive episodes associated with bipolar depression. Lurasidone is sometimes used off-label to treat bipolar mania and irritability, and anger in autism spectrum disorder.

It is thought that lurasidone affects both dopamine and serotonin receptors, while its exact mode of action is still unknown. Lurasidone fully blocks the actions of serotonin 5-HT2A and 5-HT7 receptors as well as dopamine D2 receptors. It functions as a partial agonist at the 5-HT1A serotonin receptor.

Absence in movement

Incremental movement of muscle

Mask like face

Oral Tablet-$1503.39 (20 mg from 1503.39 for 30 tablets), 40 mg from $1503.39 40 mg, 60 mg & 80mg for 30 tablets and $2239.44 for 120 mg or 30 tablets.

Carbamazepine

Tegretol

No LAI Option.

Mania: 200 mg orally twice a day.

Bipolar: 200 mg twice a day.

Following a single dosage of carbamazepine extended-release formulations, the average elimination half-life of the drug was 35 to 40 hours. Following multiple carbamazepine dosages, the half-life varied from 12 to 17 hours.

Manic episodes and mixed manic-depressive episodes caused by bipolar I disorder. Carbamazepine is indicated for treatment of epilepsy and pain associated with true trigeminal neuralgia.

By changing the conductance of sodium, potassium, or calcium or by influencing neurotransmitters such as glutamate, δ-aminobutiric acid (GABA), or other neurotransmitters that may be involved in seizure activity, carbamazepine either increases or lowers neuronal excitability or facilitates inhibition. The inactivated Na+ channel is bound by carbamazepine, which delays the inactivation of renewal. Moreover, it prevents Ca++ from entering synaptic membranes. Only at supratherapeutic doses does potentiation decrease and synaptic function is impaired.

Blurred vision

Continuous back and forth eye movement

Oral Suspension $207.80 (100mg/5mL for 450 mL), Oral Tablet $317.39 for 100 tablets.

Lamotrigine

Lamictal

No LAI Option.

Bipolar disorder: 200 mg/day; this dose may be higher or lower based on concomitant medication. Patients not taking carbamazepine, phenytoin, phenobarbital or valproate: 25 mg orally once a day (week 1 and 2), then 5o mg orally week 3 and 4, then 100 mg week 5and then increase to maintenance dose.

14-59 hours.

Mood stabilizer in bipolar disorder, maintenance dose of bipolar type 1 and used in the treatment of epilepsy.

Lamotrigine's mode of action is not totally understood. Lamotrigine is a triazine that preferentially binds to and blocks voltage-gated sodium channels, thereby preventing presynaptic glutamate and aspartate release and stabilizing presynaptic neuronal membranes.

Blurred vision

Chest pain

Decreased urine output

Dilated neck veins

Double vision

Oral Tablet (Green dose pack) $1,685.47 25mg-100mg for 98, (Orange dose pack) 25mg-100mg $847.51 for 49 tablets, (Blue dose pack) 25 mg $586.17 for 35 tablets. 25 mg from $1685.65 for 100 tablets, 100mg from $1924.07 for 100 tablets, 150 mg from $1268.56 for 60 tablets, 200 mg from $1380.12 for 6o tablets. Oral Tablet, Dispersible- 2mg, 5mg from $1631.34 for 100 tablets, 25 mg from $1250.58 for 100 tablets.

Cariprazine

Vraylar

No LAI Option.

Schizophrenia – 1.5 mg once daily.

Manic or Mixed Episodes associated with bipolar disorder- 1.5 mg once daily and should be increased to 3 mg daily on day 2.

Adjunctive therapy – 1.5 mg once daily.

Schizophrenia and acute manic or mixed episodes due to bipolar 1 disorder and depressive episodes.

In particular, cariprazine functions as an antagonist at the 5-HT2B receptors and as a partial agonist at the serotonin 5-HT1A and dopamine (DA) D2 and D3 receptors.

Blurred vision

Chills

Fever

Headache

Oral Capsule-1.5 mg-3mg $347.99 for 7 capsules, 1.5 mg from $976.63 for 20 capsules, 3mg from $976.63 for 20 capsules, 4.5 mg from $1460.18 for 30 capsules, and 6 mg from $1460.18 for 30 capsules.

Lumateperone

Caplyta

No LAI Option

Caplyta is 42 mg orally once daily with or without food. Dose titration is not required

13-18 hours.

Caplyta is used to treat the symptoms of schizophrenia. Caplyta is also used alone or with lithium or valproate to treat depression associated with bipolar disorder (manic depression).

Lumateperone blocks dopaminergic neurotransmission at the post-synaptic D2 receptor and inhibits positive feedback at D2 receptors through its pre-synaptic partial agonist action. This dual action at D2 receptors blocks post-synaptic D2 receptors and inhibits a rise in dopamine in the synaptic cleft.

Drowsiness

Lightheaded

Dry mouth

Nausea

Oral Capsule-10.5 mg from $1661.83 for 30 capsules, 21mg from $1661,83 for 30 capsules, and 42 mg from 1551.83 for 30 capsules.

Notes

Journal # 6

*Antidepressants*
Generic Name	Trade Name	Route(s) of Administration	LAI option	Starting Dose	Half Life	Indications (s/sx & diagnosis)	MOA (neurotransmitter effects)	Common Side Effects	Costs
SSRIs
Escitalopram	Lexapro	PO	No LAI	10 mg orally once a day; increase, if necessary, after at least 1 week of treatment to 20 mg once a day. Maintenance dose: 10 to 20 mg orally once a day. Maximum dose: 20 mg orally once a day.	Escitalopram has an elimination half-life of 27–32 hours; however, in individuals with decreased hepatic function, this half-life is doubled and rises by about 50% in the elderly. S-desmethylcitalopram, the principal metabolite of escitalopram, with an elimination half-life of roughly 54 hours at steady state.	Escitalopram is prescribed for the acute treatment of generalized anxiety disorder (GAD) in adults and pediatric patients aged 7 and older, as well as for the maintenance and acute treatment of major depressive disorder (MDD) in patients aged 12 and older. In Canada, it is also recommended for the symptomatic treatment of obsessive-compulsive disorder (OCD).	Like other selective serotonin re-uptake inhibitors, escitalopram increases serotonergic activity by binding to the orthosteric (primary) binding site on the serotonin transporter (SERT), the same site to which endogenous 5-HT binds. This prevents serotonin from being re-absorbed into the presynaptic neuron. Eventually, the sustained elevation of synaptic 5-HT leads to desensitization of 5-HT1A auto-receptors, which normally shut down endogenous 5-HT release in the presence of excess 5-HT. This desensitization may be required for the full clinical effect of SSRIs and may be the cause of their typically delayed onset of action.	Dizziness, drowsiness, weakness, insomnia, nausea, constipation, yawning, nosebleed, heavy menstrual periods, decreased sex drive, impotence, feeling anxious or agitated.	5 mg tablet for 100 tablets $1414.00 10 mg tablets for 100 tablets $1478.00 20 mg tablets for 30 tablets $104.55.
Sertraline	Zoloft	PO	No LAI	Depending on tolerance, following dosages for adults and pediatric patients may be increased in increments of 25 to 50 mg once a week in the event of an unsatisfactory response, with a daily maximum of 200 mg. MDD: 50 mg OCD: 50 mg PD, PTSD, SAD: 25 mg	Sertraline has an elimination half-life of roughly 26 hours.	Major depressive disorder (MDD), obsessive-compulsive disorder (OCD), panic disorder (PD), premenstrual dysphoric disorder (PMDD), social anxiety disorder (SAD), and post-traumatic stress disorder (PTSD) can all be treated with sertraline.	Sertraline increases serotonergic activity by specifically blocking serotonin (5-HT) reuptake at the presynaptic neuronal membrane. This causes the CNS's synaptic serotonin concentration to rise, which causes a variety of functional alterations linked to an increase in serotonergic neurotransmission. The antidepressant action and positive benefits in OCD (and other anxiety related diseases) are thought to be caused by these modifications.	Indigestion, loss of appetite, diarrhea, increased sweating, tiredness, sleep problems, insomnia, loss of bladder control, tremors or agitation, or sexual problems.	150 mg oral capsule for 30 $172.00 200 mg oral capsule for 30 capsules $172.00.
Fluoxetine	Prozac	PO	No LAI	Formulations for oral immediate release: First dose: 20 mg taken orally once day in the morning; if adequate clinical improvement is not seen after a few weeks, the dose may be increased. Daily maintenance dose: 20–60 mg taken orally. A daily maximum dose is 80 mg taken orally. Oral delayed-release capsules: First dose: 90 mg taken once a week by mouth, starting seven days following the last 20 mg dose of immediate-release fluoxetine formulations administered daily.	Fluoxetine has a long half-life, with the main drug's elimination half-life typically occurring 1-3 days after acute treatment and 4-6 days after chronic administration. Additionally, norfluoxetine, its active metabolite, has an elimination half-life of 4–16 days following both acute and long-term dosing. Since significant buildup happens during prolonged usage, the half-life of fluoxetine should be taken into account when transferring patients from fluoxetine to another antidepressant. Due to its extended half-life, which reduces the chance of withdrawal, fluoxetine may even be advantageous when stopping the medication.	Although it is only recommended for the acute treatment of panic disorder, regardless of the presence of agoraphobia, fluoxetine is approved for the treatment of major depressive disorder, bulimia nervosa, and obsessive-compulsive disorder. Additionally, treatment-resistant depression and depression associated with Bipolar I Disorder can be managed with fluoxetine in conjunction with olanzapine. For female patients with premenstrual dysphoric disorder (PMDD), fluoxetine is also recommended.	As the name implies, fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that works by preventing serotonin from being reabsorbed into the brain synapses. Consequently, different regions of the brain see a rise in 5-hydroxytryptamine (5-HT) levels. Moreover, fluoxetine is 5-HT selective since it has a strong affinity for 5-HT transporters, a low affinity for noradrenaline transporters, and no affinity for dopamine transporters. There is evidence to suggest that fluoxetine increases noradrenaline and dopamine levels in the prefrontal cortex by partially interacting with the 5-HT2C receptor.	Insomnia, strange dreams, vision changes, headaches, dizziness, pain, weakness, upset stomach, loss appetite, hot flashes, stuffy nose, sinus pain, flu symptoms, decreased sex drive, impotence, and difficulty having an orgasm.	10 mg – 30 capsules: $12.00. 20 mg-30 capsules for $12.22. 40 mg oral capsule-$13.33 for 30 capsules.
Paroxetine	Paxil	PO	No LAI	The starting dose for MDD: 20 mg, Max dose, 50 mg, OCD: starting dose 20 mg, Max dose 60 mg, PD 10 mg, 60 mg Max dose, PTSD: 20 mg starting dose, 50 mg Max dose.	Paroxetine has an average half-life of 21 hours for elimination. The mean elimination half-life in young, healthy participants was determined to be 17.3 hours.	A selective serotonin reuptake inhibitor, paroxetine is prescribed to treat a variety of conditions including major depressive disorder, panic disorder, OCD, social anxiety, generalized anxiety disorder, menopausal vasomotor symptoms, and premenstrual dysphoric disorder.	By preventing the serotonin (SERT) receptor from presynaptically reabsorbing serotonin, paroxetine increases serotonergic activity. Many symptoms are alleviated when serotonin levels in the synaptic cleft are raised due to this inhibition. The prescribing description for Brisdelle states that although the exact mechanism of action of paroxetine in reducing the vasomotor symptoms of menopause is uncertain, it may be related to its effects on thermoregulation.	Weakness, drowsiness, dizziness, sweating, anxiety, shaking, loss of appetite, infection, headache, vision changes, insomnia, dry mouth, abnormal ejaculation, and tiredness.	The cost for Paxil oral tablet 10 mg is around $292 for a supply of 30 tablets, depending on the pharmacy you visit. 10 mg tablets-291.66 20 mg tablets-303.93 30 mg tablets-312.88 40 mg tablets-329.99
Citalopram	Celexa	PO	No LAI	Administer Celexa once daily, with or without food, at an initial dose of 20 mg once daily, with an increase to a maximum dosage of 40 mg daily at an interval of not less than one week.	The mean terminal half-life of citalopram is about 35 hours.	The FDA has approved citalopram as a treatment for major depressive disorder in adults. Off-label use has also been utilized to treat a variety of illnesses, including as diabetic neuropathy, ethanol misuse, obsessive-compulsive disorder (OCD), social anxiety disorder, panic disorder, and sexual dysfunction.	Although citalopram's exact mode of action is unknown, it is thought to involve potentiating serotonergic activity in the central nervous system (CNS) by inhibiting serotonin (5-HT) neuronal reuptake in the CNS, possibly by blocking the serotonin transporter (solute carrier family 6 member 4, SLC6A4). Compared to tricyclic antidepressants, citalopram binds to histamine, acetylcholine, and norepinephrine receptors with a substantially lower affinity. In particular, citalopram exhibits negligible or no affinity for the following receptors: histamine H1, gamma aminobutyric acid (GABA), benzodiazepine, dopamine D1 and D2, α1-, α2-, and β-adrenergic, muscarinic cholinergic, and histamine H1.	Dizziness, drowsiness, sexual problems, dry mouth, loss of appetite, nausea, constipation, cold symptoms, feeling anxious, agitated, or shaky, and increased muscle movement.	10 mg tablets-965.33 for 100 tablets. 20 mg tablets for 100 $1005.77. 40 mg tablet for 1049.10 for 100 tablets.
Fluvoxamine	Luvox	PO	No LAI	Dosage for the first immediate-release tablet: 50 mg taken once daily at night. Dosage for the first extended-release capsule: 100 mg taken once day at night. Daily maintenance dose: 100–300 mg taken orally. Daily maximum dose: 300 mg Until the greatest therapeutic benefit is obtained, the dose may be raised in 50 mg increments every 4 to 7 days, as tolerated. If the daily dosage exceeds 100 mg, it should be administered in two separate doses. The higher dose should be administered at bedtime if the doses are not equal.	Fluvoxamine has a half-life of 15.6 hours.	Fluvoxamine mostly used to treat depression and the label of obsessive-compulsive disorder (OCD). been applied to the treatment of bulimia nervosa as well.	Although the precise mode of action of fluvoxamine is yet unknown, it seems to be related to the suppression of serotonin label absorption by CNS neurons. Fluvoxamine increases the effects of serotonin on 5HT1A autoreceptors by blocking the reuptake of serotonin at the neuronal membrane's serotonin reuptake pump. Research has also shown that fluvoxamine, while it has an affinity for binding to σ1 receptors, essentially has no affinity for α1- or α2-adrenergic, β-adrenergic, muscarinic, dopamine D2, histamine H1, GABA-benzodiazepine, opiate, 5-HT1-, or 5-HT2 receptors	Inability to have or keep an erection, loss in sexual ability, desire, drive, or performance, decreased interest in sexual intercourse.	100 mg capsules ER for 30 capsules: 189.22 150 mg capsules ER for 30 198.22.
SNRIs
Duloxetine	Cymbalta	PO	No LAI	Initial dosage: two times a day, 20–30 mg taken orally Maintenance dose: 30 mg taken twice day OR 60 mg taken once daily orally Dosage maximum: 120 mg daily. Standard Adult Dosage for Anxiety Disorder: Initial dosage: 60 milligrams taken once daily by mouth. Maintenance dosage: 60–120 mg taken once a day by mouth. Dosage maximum: 120 mg daily	Duloxetine half-life is a mean of 12 hours with a range of 8-17.	Duloxetine is indicated for major depressive disorder and generalized anxiety disorder. Duloxetine is a serotonin norepinephrine reuptake inhibitor also used to treat neuropathic pain, osteoarthritis, and stress incontinence.	Neuronal serotonin and norepinephrine reuptake is strongly inhibited by duloxetine, although dopamine reuptake is less strongly inhibited by this drug. Duloxetine exhibits little affinity for opioid, glutamate, GABA, histaminergic, cholinergic, adrenergic, and dopaminergic receptors. Duloxetine's central nervous system actions mediate its action on the external urethral sphincter. Elevated concentrations of serotonin and norepinephrine within Onuf's nucleus result in heightened activation of α1 adrenergic receptors, 5-HT2, and 5-HT3. The activation of 5-HT2 and α1 enhances the activity of the inositol trisphosphate/phospholipase C (IP3/PLC) pathway since they are both Gq linked. This process raises intracellular calcium concentrations, releases intracellular calcium reserves, and promotes neuronal excitability. When 5-HT3 is active, it acts as a ligand-gated sodium channel that permits sodium to enter the cell.	Dry mouth, increased sweating, nausea, constipation, loss of appetite, and drowsiness.	20 mg capsules $17.77 for 60. 30 mg capsules $15.24 for 30. 40 mg capsules $83.33 for 30. 60 mg capsules $19.77 for 30.
Desvenalafaxine	Pristiq	PO	No LAI	Pristiq is prescribed at a dose of 50 mg once daily, with or without food. The initial dose and therapeutic dose are both 50 mg. Every day, Pristiq should be taken at roughly the same time. Tablets should not be split, broken, chewed, or dissolved; instead, they should be eaten whole with liquid.		For the treatment of major depressive disorder in adults, desvenlafaxine is recommended. It has also been used off-label to treat menopausal women's hot flashes.	Although the precise mechanism of desvenlafaxine's antidepressant effect is unclear, it is believed to be connected to the central nervous system's potentiation of serotonin and norepinephrine through suppression of their absorption. In particular, it has been discovered that desvenlafaxine inhibits the dopamine, norepinephrine, and serotonin transporters with differing degrees of affinity. Desvenlafaxine inhibits dopamine transporters with the lowest affinity and serotonin transporters with ten times the affinity of norepinephrine transporters.	Increased sweating, dizziness, anxiety, drowsiness, nausea, decreased appetite, constipation, insomnia, impotence, difficulty having an orgasm, and decreased sex drive.	25 mg for 30 tablets $470.66. 50 mg tablets for 14 $224.77. 100 mg XR $224.77 for 14.
Effexor	Venlafaxine	PO	No LAI	The recommended starting dose of Effexor XR for the majority of patients is 75 mg given once daily. To give new patients time to get used to the medicine, it can be preferable for some individuals to begin at 37.5 mg daily for four to seven days before increasing to 75 mg daily. Doses up to 225 mg daily may be beneficial for patients who do not respond to the initial 75 mg dose. If necessary, dose increases should be made in increments of up to 75 mg per day, and they should be spaced out by at least four days.	The apparent elimination half-life is 5 ± 2 hours for venlafaxine and 11 ± 2 hours for ODV.	Venlafaxine is indicated for the management of major depressive disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder.	Though its precise mode of action in treating different psychiatric conditions is still unclear, venlafaxine and its active metabolite O-desmethylvenlafaxine (ODV) are known to potently and selectively block serotonin and norepinephrine reuptake at the presynaptic terminal. As a result, there are more neurotransmitters that can activate postsynaptic receptors at the synapses. Venlafaxine is thought to have a 30-fold selectivity for serotonin as opposed to norepinephrine since, at low doses, it inhibits serotonin reuptake alone; at higher concentrations, it also inhibits norepinephrine reuptake. ODV and venlafaxine are likewise modest dopamine reuptake inhibitors.	Fast heartbeats, nausea, diarrhea, constipation, changes in weight or appetite, tremors, headache, dizziness, tiredness, ringing in your ears, nervous, jittery, unusual dreams, yawning, dry mouth, increased sweating, and tiredness.	37.5 mg capsule XR for $524.00 for 30. 75 mg XR capsule for 30 $586.00. 150 mg capsule for 6$37.55 for 30 capsules.
Milnacipran	Savella	PO	No LAI	Savella is prescribed at a dose of 100 mg per day (50 mg twice a day). The following regimen for titrating dosage can be used, depending on effectiveness and tolerability: Day 1: once on 12.5 mg Days 2-4: 12.5 mg twice a day, or 25 mg each day Days 4 through 7: 50 mg per day (twice daily) Following Day 7: 100 mg per day (twice daily).	Racemic milnacipran has a reported terminal elimination half-life of roughly 6–8 hours, although d-milnacipran has a longer elimination half-life of 8–10 hours than l-enantimer, which is 4-6 hours. On the other hand, a terminal elimination half-life of roughly 12 hours has been found especially for levomilnacipran formulations.	Milnacipran is a short-term treatment for major depressive disorder and fibromyalgia. It is a selective serotonin and norepinephrine reuptake inhibitor (SNRI).	Milnacipran's dual action of inhibiting serotonin (5HT) and norepinephrine (NE) reuptake makes it an effective treatment for major depressive disorder (MDD) as well as fibromyalgia. Specifically, it is commonly accepted that 5HT and NE influence endogenous analgesic mechanisms through the brain and spinal cord's descending inhibitory pain pathways. Milnacipran's ability to increase the presence of 5HT by blocking its reuptake via serotonin transporters at synaptic clefts may help alleviate increased sensitivity to pain, even though the precise mechanism of action is still unknown. Some studies have suggested that low levels of 5HT may be linked to this condition.	Dry mouth, constipation, nausea, vomiting, fast or pounding heartbeats, trouble sleeping, dizziness, headache, increased blood pressure, and trouble sleeping.	The average cost for 30 Tablet(s), 100MG Tablets each, is $441.94. You can buy Savella at the discounted price of $250.59 by using the WebMDRx coupon, a savings of 43%.
Levomilnacipran	Fetzima	PO	No LAI	For Fetzima, 40 mg to 120 mg once daily, with or without food, is the recommended dosage range. For two days, start Fetzima at 20 mg once daily; after that, raise it to 40 mg once daily. Fetzima may be raised in increments of 40 mg at intervals of two or more days, contingent on clinical response and tolerability. One dosage of 120 mg per day is the maximum that is advised.	Levomilnacipran extended release has an apparent terminal elimination half-life of about 12 hours.	A serotonin and norepinephrine reuptake inhibitor called levomilnacipran is prescribed to individuals with major depressive disorder (MDD).	A strong and effective selective serotonin and norepinephrine reuptake inhibitor (SNRI) is levomilnacipran. Levomilnacipran's precise antidepressant action is unknown, however it is believed to be connected to the central nervous system's potentiation of serotonin and norepinephrine through inhibition of reuptake at serotonin and norepinephrine transporters. Similar to milnacipran, levomilnacipran shows a selectivity for norepinephrine vs serotonin reuptake inhibition that is more than 15 times higher than that of milnacipran. It is a more potent inhibitor of the norepinephrine transporter than the serotonin transporter.	Constipation, vomiting, irregular heartbeats, sweating, nausea, decreased sex drive, impotence, and difficulty having an orgasm.	20 mg-40 mg $478.77 for 28 capsules. 20 mg capsule, ER for 30 capsules $512.22. 40 mg capsule for 30 $512,22. 80 mg tablets for 30 $512.22.
TCAs
Amitriptyline	Elavil	PO	No LAI	For tablet dosage types (oral): Regarding depression: Adults: 50–100 mg at bedtime, or 75 mg per day administered in split doses. Your dosage may need to be changed by your doctor. Nonetheless, unless you are hospitalized, the dosage is typically not higher than 150 mg daily. Certain hospitalized individuals could require larger dosages. Adolescents and senior citizens: take 10 mg three times a day, plus an additional 20 mg right before bed.	After oral treatment, the elimination half-life (t1⁄2 β) of amitriptyline is approximately 25 hours (24.65 ± 6.31 hours; range 16.49-40.36 hours	Amitriptyline is a tricyclic antidepressant that is prescribed to treat endogenous or psychotic depression and to reduce anxiety related to depression.	This medication's exact mode of action is unknown. Amitriptyline is thought to increase the concentration of transmitter amines in the brain's synaptic clefts by blocking the membrane pump mechanism that allows chemicals like norepinephrine and serotonin to be reabsorbed. These amines play a significant role in mood regulation. One of the first theories on depression is the monoamine hypothesis, which suggests that depression results from deficits in serotonin (5-HT) and/or norepinephrine (NE) neurotransmission in the brain. Amitriptyline may work by counteracting these systems, which is how it helps to alleviate depression symptoms.	Nausea, vomiting, upset stomach, constipation, diarrhea, itching, rash, breast swelling, decreased sex drive, impotence, mouth pain, unusual taste, black tongue, appetite or weight changes, and difficulty having an orgasm.	10 mg $10.89 for 15. 25 mg oral tablet for $13.45. 50 mg tablets-$18.19 for 29 tablets. 75 mg-$38.99 for 50. 100 mg $40.85 for 50 tablets. 150 mg $96.45 for 100 tablets.
Doxepin	Silenor	PO	No LAI	For oral dose forms (capsules or solution): For treating anxiety or depression: For adults and kids 12 years old and up, start with 75 mg once day or divide it up throughout the day. Nonetheless, the daily intake is often limited to 150 mg. Children under the age of twelve should not use this product. For pills used orally: For sleeplessness. 6 mg. once daily for adults. Elderly adults: 3 mg once daily initially.	It is stated that the average elimination half-life of Doxepin is fifteen hours.	The following indications are approved for doxepin: treatment for anxiety or depression, therapy for anxiety and/or depression brought on by a variety of illnesses, such as a biological illness, alcoholism, and manic-depressive disorders, treatment for anxiety-related psychotic depressions, therapy for depressive involution, therapy for manic-depressive illness, therapy for insomnia, a condition marked by trouble maintaining sleep.	The precise mode of action of doxepin is unclear. On the other hand, doxepin is a recognized selective histamine H1 receptor antagonist. This action on histamine receptors suggests that skin diseases can be effectively treated. Doxepin's antidepressant effects, which vary depending on the effect, are mostly linked to the inhibition of biogenic amine reuptake in the central nervous system, specifically the absorption of norepinephrine and serotonin at synaptic nerve terminals. Due to this impact, there is an increase in monoamine levels at the synaptic site, which in turn causes an increase in activity at the receptor sites of post-synaptic neurons. It's been proposed that doxepin additionally desensitizes beta-adrenergic and serotonin receptors.	Nausea, cold symptoms, sore throat, drowsiness, and tiredness.	25 mg oral capsule: $15.50 for 30. 25 mg oral capsule: $16.89 for 30. 50 mg oral capsule: $25.99 for 90. 75 mg oral capsule: $32.24 for 90.
Nortriptyline	Pamelor	PO	No LAI	For oral dose forms, such as capsules or solutions: Concerning depression: Adults: three to four times a day, 25(mg). Nonetheless, the daily intake is often limited to 150 mg. Adolescents and senior citizens: 30 to 50 mg once daily, or in smaller doses throughout the day.	Nortriptyline's plasma half-life is reported to vary from 16 to 38 hours, with an average of about 26 hours in healthy participants. According to one study, the mean half-life is roughly 39 hours.	The medication nortriptyline is prescribed to treat major depressive disorder (MDD) symptoms. The medication may be used off-label to treat neuralgia, myofascial pain, chronic pain, and irritable bowel syndrome.	Despite the fact that the prescribing instructions for nortriptyline does not specify its exact mode of action, it is thought to work either at the level of beta-adrenergic receptors or by blocking the reuptake of the neurotransmitter serotonin at the neuronal membrane. It exhibits a more selective noradrenaline reuptake inhibition, which could account for the greater improvement in symptoms following nortriptyline medication. Tricyclic antidepressants have little effect on dopamine reuptake or monoamine oxidase inhibition. Nortriptyline exhibits affinity for a variety of receptors, such as mACh, histamine, and 5-HT receptors, in addition to other receptors, as other tricyclics do.	Blurred vision, increased blood pressure, numbness or tingling in your feet or hands, dry mouth, nausea, vomiting, loss of appetite, rash, itching, and breast swelling.	10 mg capsule: $15.25 for 30. 25mg oral capsule: $20.99 for 30. 50 mg capsule: $25.90 for 90. 75 mg oral capsule: $32.21 for 90.
Imipramine	Tofranil	PO	No LAI	Oral dose form (capsules): Adults with depression: 75 mg once daily at first. Nonetheless, unless you are hospitalized, the dosage is typically not higher than 200 mg daily. Certain hospitalized individuals could require larger dosages. Adolescents and elderly adults: Take the pills for 25 to 50 mg daily at first. But often, the dosage doesn't exceed 100 mg daily. Children: Your doctor must establish the appropriate use and dosage. Oral dosage form (tablets): Adults with depression: 75 mg daily initially. Your dosage may need to be changed by your doctor. Nonetheless, the daily intake is often limited to 200 mg. Some hospitalized individuals could require larger dosages. Adults over the age of thirty to forty milligrams each day.	The average half-life of imipramine is twelve hours. Desipramine, its active metabolite, has a mean half-life of 22.5 hours.	Imipramine is used to treat depression symptoms and, in children six years of age and older, as a short-term adjunctive therapy to lessen enuresis. Off-label uses include managing panic disorders with or without agoraphobia, treating posttraumatic stress disorder and acute stress disorder, managing bulimia nervosa, treating ADHD in children and adolescents, managing acute depressive episodes in bipolar disorder and schizophrenia, and treating postherpetic neuralgia and painful diabetic neuropathy.	Imipramine functions by preventing norepinephrine and serotonin from being reabsorbed by neurons. It decreases the amount of norepinephrine and serotonin that neurons absorb by binding the sodium-dependent serotonin transporter and sodium-dependent norepinephrine transporter. A deficiency in norepinephrine and serotonin activation of the post-synaptic neuron has been associated with depression. Reuptake of these neurotransmitters is slowed down, which raises their concentration in the synaptic cleft and causes knock-on effects on protein kinase signaling. These changes in brain physiology and neurotransmission are believed to be responsible for alleviating depression symptoms.	Increased blood pressure, dry mouth, tingly feeling, weakness, lack of coordination, breast swelling, nausea, dry mouth, and. vomiting.	75 mg capsule: $364.72 for 30. 200 mg capsule: $376.22 for 30. 125 mg capsule: $439.37 for 30 capsules. 150 mg capsule: $186.51 for 30.
Clomipramine	Anafranil	PO	No LAI	For the oral dose form (capsules): In relation to obsessive compulsive disorder: Adults: Take 25 milligrams (mg) at bedtime once a day at initially. Larger doses can be administered throughout the day in parts that are equally divided. Nonetheless, the daily intake is often limited to 250 mg. Children ten years of age and up: 25 mg once daily at night. Larger doses can be administered throughout the day in parts that are equally divided. Nonetheless, the daily intake is often limited to 200 mg.	The average elimination half-life of desmethylclomipramine was 69 hours (range: 54-77 hours) and of clomipramine was 32 hours (range: 19-37 hours) after an oral 150 mg dosage. Because of saturable kinetics, elimination half-lives can differ significantly between dosages.	Obsessive-compulsive disorder and disorders exhibiting an obsessive-compulsive component can be treated with clomipramine. Tourette's syndrome, schizophrenia, and depression. Depression, panic disorder, tension headache, idiopathic pain disorder, central pain, diabetic peripheral neuropathy, neuropathic pain, cataplexy and related narcolepsy, and autism disorder are among the unlabeled indications.	Because its primary active metabolite, desmethyclomipramine, preferentially functions as an inhibitor of noradrenaline reuptake, clomipramine is a potent, albeit not entirely selective, serotonin reuptake inhibitor (SRI). There is evidence of α1-receptor blocking and β-down-regulation, which presumably contributes to the short-term effects of clomipramine. The mechanism of action of tricyclics, similar to other medications, in chronic pain, especially neuropathic pain, may involve blocking sodium channels and NDMA receptors.	Sweating, feeling dizzy, drowsy, tired, nervous, urination problems, vision changes, decreased sex drive, impotence, difficulty having an orgasm, tremors, and jerking movements.	25 mg tablet- quantity 30: $24.80. 50 mg capsule quantity 30: $25.44. 75 mg capsule quantity 30: $28.10.
MAOIs
Phenelzine	Nardil	PO	No LAI	Regarding tablet dosage forms (oral): Regarding depression: Adults:15(mg) three times a day at initially. But the daily dose is typically not higher than 90 mg. Children: It is not advised to use.	In individuals, phenelzine has an extremely brief half-life of 11.6 hours following ingestion.	A monoamine oxidase inhibitor called phenelzine is used to treat neurotic, nonendogenous, or atypical depression.	Phenelzine's basic mode of action is acting as a substrate and inhibitor of monoamine oxidase, which raises serotonin and catecholamine levels in the brain. Its structural resemblance to amphetamine also accounts for its effects on serotonin, noradrenaline, and dopamine uptake and release. It has been observed that phenelzine inhibits dopamine B-hydroxylase, aromatic amino acid decarboxylase, and tyrosine aminotransferase.	Dizziness, headache, tremors, sexual problems, weight gain, drowsiness, sleep problems, muscle twitching, stomach discomfort, and constipation.	Phenelzine 15 mg $44.57 for a quantity of 60 tablets.
Tranylcypromine	Parnate	PO	No LAI	Regarding tablet dosage forms (oral): Regarding depression: Adults:15 milligrams (mg) three times a day at initially. Your dosage may need to be changed by your doctor. But the daily dose is typically not higher than 90 mg. Children: It is not advised to use.	1.5–3.2 hours in individuals with typical hepatic and renal function	A monoamine oxidase inhibitor called tranylcypromine is used to treat major depressive disorder.	Monoamine oxidase (MAO) is permanently and nonselectively inhibited by truncypromine. It appears that MAO controls the number of monoamines released by synaptic firing in neurons. Since depression is linked to low monoamine levels, inhibiting MAO reduces depressed symptoms by raising the concentrations of these amines in the central nervous system.	Headache, constipation, dizziness, drowsiness, blurred vision, trouble sleeping, dry mouth, feeling shaky or excited.	Tranylcypromine 10 mg ($97.50) for a quantity of 100.
Selegiline	Emsam	PO/Transdermal	No LAI	For oral dosage forms (tablets or capsules): For Parkinson's disease: Adults: Take five milligrams (mg) at breakfast and lunch, twice a day. Regarding oral disintegrating pills, or oral dose form: Adults: Take 1.25 mg once daily, preferably before breakfast, for a minimum of six weeks. Your doctor might up your dosage to 2.5 mg once daily after six weeks.	1.2-2 hours	Selegiline is used as a monotherapy to treat Parkinson's disease initially and as an additional therapy for those who do not respond well to levodopa/carbadopa. Additionally used, at greater doses, to treat depression and as a palliative care for mild to moderate Alzheimer's disease.	Although the exact processes underlying selegiline's favorable effects in treating Parkinson's disease remain unclear, it is believed that the selective and permanent inhibition of monoamine oxidase type B (MAO-B) is a key factor. In the brain, dopamine undergoes oxidative deamination through the involvement of MAO-B. Selegiline binds to MAO-B in the central nervous system's nigrostriatal pathways, inhibiting dopamine's microsomal metabolism and boosting dopaminergic activity in the significant nigra. Apart from inhibiting MAO-B, selegiline may potentially raise dopaminergic activity by additional means. Selegiline can be used to treat depression because, at larger doses, it also inhibits monozmine oxidase type A (MAO-A).	Sinus pain, stuffy nose, headache, redness or itching on the patch site, upset stomach, diarrhea, dry mouth, insomnia, and rash.	Selegiline 5 mg oral capsule $36.30 for a quantity of 30. Selegiline 5 mg tablets ($116.69) for q quantity of 60.
Isocarboxazid	Marplan	PO	No LAI	For oral dosage form (tablets): For depression: Adults—At first, 10 milligrams (mg) two times a day. However, the dose is usually not more than 60 mg per day. Children—Use is not recommended.	Although the pharmacokinetic profile of isocarboxazid has not been well investigated, it is believed that its characteristics should resemble those of several analogs, such as tranylcypromine and phenelzine. Since isocarboxazid is an irreversible monoamine oxidase inhibitor, its half-life is not very important. Because of their quick hepatic metabolism, these medications have an extremely short half-life of 1.5–4 hours.	A monoamine oxidase inhibitor called isocarboxazid is used to treat persistent and debilitating depression symptoms when other antidepressant medications have not shown a sufficient clinical response.	Isocarboxazid functions by permanently inhibiting the neurological system's monoamine oxidases (MAO). The metabolism of catecholamine and serotonin neurotransmitters, including dopamine, adrenaline, and norepinephrine, is mediated by MAO subtypes A and B. Isocarboxazid binds irreversibly to both monoamine oxidase-A (MAO-A) and monoamine oxidase-B (MAO-B) as a nonselective MAO inhibitor. Like other monoamine oxidase inhibitors, isocarboxacid is a special psychopharmacological substance whose therapeutic impact is associated with the monoamine oxidases' direct conversion of the compounds into reactive metabolites.	Tremors, drowsiness, dizziness, insomnia, constipation, nausea, and dry mouth.	Oral tablets 10 mg for a quantity of 100 ($531.55).
Atypical
Aripiprazole	Abilify	PO/IM	Aristada	Schizophrenia- 10 mg or 15 mg by mouth once a day. Parenteral Formulations- 400 mg IM once, continue aripiprazole IR 10 to 20 mg orally for 14 days. Bipolar Disorder-15 mg by mouth once a day. Adjunctive Therapy-10 mg to 15 mg by mouth once a day. Parenteral Formulation- 400 mg IM once; continue aripiprazole IR 10 to 20 mg orally once a day for 14 days.	75 hours (Aripiprazole) 94 hours (major metabolite dehydro-aripiprazole).	Symptomatic management of psychosis in patients with schizophrenia and monotherapy or adjunctive therapy for acute manic episodes associated with bipolar disorder. The oral tablet and solutions are used to treat autistic spectrum disorder. Aripiprazole can also serve as an adjunctive treatment for major depressive disorder and Tourette syndrome.	Aripiprazole is a partial agonist at D2 receptors. It may act as an antipsychotic by lowering dopaminergic neurotransmission in the mesolimbic pathway. Enhancing dopaminergic activity in the mesocortical pathway.	Increased saliva, drooling, muscle stiffness, nausea, vomiting, headache, cold symptoms, insomnia, dizziness, feeling tired, weight gain, blurred vision, shaking, anxiety, feeling restless, increased or decreased appetite, and constipation.	Oral Solution $275.12 for 150mL, Oral tablets-$11.80 for 2mg tablets-30 tablets, $12.25 5mg tablets- for 30 tablets, $13.17 for 10 mg-30 tablets. Oral disintegrating- $712.48 (10 mg for 30 tablets), $760.97 (15 mg for 30 tablets).
Olanzapine	Zyprexa	IM/PO	Zyprexa Relprevv	Bipolar Disorder – 10 mg to 15 mg orally once a day. Adjunctive Treatment – 10 mg orally once a day. Depressive Episodes with Bipolar I Disorder – 5 mg by mouth once a day. Schizophrenia – 5mg to 10 mg orally once a day. Parenteral – 210 mg IM every 2 weeks or 405 mg IM every 4 weeks for the first 8 weeks. Depression – 5 mg orally once a day. Agitated State – 10 mg IM once. Geriatric – Agitated State- 5 mg IM once. Pediatric dose for Schizophrenia- 2.5 mg to 5 mg orally once a day.	Olanzapine has a half-life that ranges from 21 to 54 hours, with a half-life average of 30 hours.	Zyprexa is used to treat psychotic illnesses in adults and children who are at least 13 years old, including schizophrenia and bipolar disorder (manic depression). In addition, adults and children with bipolar I disorder who are at least ten years old and experience depressive episodes are treated with Zyprexa in addition to fluoxetine (Prozac).	Olanazapine exerts its action primarily on dopamine and serotonin receptors. It works on dopamine D2 receptors in the mesolimbic pathway as an antagonist, blocking dopamine from potential action at the post synaptic receptor.	Headache, dizziness, drowsiness, problems with speech or memory, changes in personality, dry mouth, increased salivation, stomach pain, constipation, pain in arms or legs, weight gain, tremors, numbness or tingly feeling, and increased appetite.	Intramuscular-10 mg from $62.42 for 1 powder injection. Oral Tablet-2.5 mg from $431,23 for 30 tablets, 5 mg from $507.04 for 30 tablets, 7.5 mg from $614.75 for 30 tablets, 10 mg from $759.13 for 30 tablets, 15 mg from $1133.95 for 30 tablets, and 20 mg from $1508.76 for 30 tablets.
Asenapine	Saphris	SL/Transdermal	No LAI Option.	Schizophrenia – 5 mg sublingually 2 times a day. Bipolar Disorder – 10 mg sublingually 2 times a day. Adjunctive therapy – 5 mg sublingually 2 times a day. Bipolar (Pediatric) 2.5 mg sublingually 2 times a day.	24 hours (range of 13,4-39.2 hours).	Atypical antipsychotic for treatment of schizophrenia and acute mania associated with bipolar disorder. Asenapine also belongs to the dibenzo-oxepine pyrrole class. It is also for severe post-traumatic stress disorder nightmares in soldiers as an off-label use.	Asenapine is an atypical antipsychotic multireceptor neuroleptic drug which shows strong 5HT2A (serotonin) and D2 (Dopamine) receptor antagonism.	Feeling tired, agitated, dizziness, drowsiness, tiredness, muscle stiffness, jerky muscle movement, nausea, altered sense of taste, increased appetite, weight gain, numbness or tingling in or around the mouth.	Sublingual - $1,111.35 (2.5 mg for 60 tablets), $239.00 (5mg for 60 tablets), $ 239.00 (10 mg for 60 tablets). Transdermal – 30 quantity $47.20 per unit.
*Anxiolytics*
Benzodiazepines
Alprazolam	Xanax	PO/Sublingual	No LAI	For the acute treatment of patients with GAD, an initial oral dosage of 0.25 mg to 0.5 mg given three times per day is advised. Every three to four days, the dosage may be changed based on the reaction. The highest amount that is advised is 4 mg per day, divided into smaller dosages. For the treatment of Parkinson's disease (PD), an initial oral dosage of 0.5 mg three times per day is advised. The dosage may be adjusted every three to four days in increments of no more than one milligram per day, depending on the reaction.	In healthy individuals, the mean plasma elimination half-life of alprazolam is 11.2 hours (range: 6.3-26.9 hours).18 The average half-life for aged patients is 16.3 hours (range 9.0-26.9 hours), for obese patients it is 21.8 hours (range 9.9-40.4 hours), and for patients with alcoholic liver disease it is 19.7 hours (range 5.8-65.3 hours).	Adults with generalized anxiety disorder may benefit from the acute treatment of alprazolam. In addition, adults with panic disorder and agoraphobia may benefit from either normal or extended-release formulations of alprazolam. Off-label prescriptions for depression, premenstrual syndrome, and sleeplessness are also available for alprazolam.	Both excitatory and inhibitory signals are necessary for neurotransmission. Members of the pentameric ligand-gated ion channel (PLGIC) superfamily, γ-aminobutyric acid (GABA) type-A receptors (GABAARs) are found extrasynaptically to mediate tonic inhibition and synaptically and perisynaptically to mediate phasic inhibition. GABAARs are made up of a range of subunits from a homologous family whose members are called α1-6, β1-3, γ1-3, δ, ε, θ, π, and ρ1-3 depending on sequence identity. Inter-subunit interfaces, which are defined by the coordination of the major (+) and complementary (-) sites in each subunit, are the key locations of neurotransmitter and modulator binding. Each subunit has an extracellular (ECD), transmembrane (TMD), and intracellular (ICD) domain. GABA binding to GABAARs causes synaptic hyperpolarization, pore opening, and fast chloride ion influx, all of which result in an inhibiting signal.	Feeling light-headed and dizziness.	Oral Xanax tablet 0.25 mg is around $556 for a supply of 100 tablets, $5.48 for a quantity 500, 0.5 mg supply of 100 $6.90, 0.5mg supply of 500 $6.83, 1 mg $9.18 for quantity of 100, 1 mg $9.10 for a quantity of 500, and 2 mg $15.54 for a quantity of 100.
Clonazepam	Klonopin	PO	No LAI	Adults with panic disorder should start with 0.25 mg twice a day. After three days, an increase to the target dose of 1 mg/day may be done for many individuals. Based on the findings of a fixed dose research, wherein 1 mg/day produced the best impact, the recommended amount is 1 mg/day.	Clonazepam's mean elimination half-life, which has been reported to range between 30 and 40 hours, is independent of the dosage administered.	A long-acting benzodiazepine with an intermediate onset, clonazepam is frequently used to treat seizures, severe anxiety, and panic disorders.	It is thought that the main inhibitory neurotransmitter in the human body is gamma-aminobutyric acid (GABA). An ion channel in the GABA(a) receptors allows chloride ions to pass through neuron cell membranes when GABA binds to the receptors, which are present in neuron synapses. The local, related neuron membrane potentials become hyperpolarized when sufficient chloride ions are transmitted. This increases the likelihood or difficulty of action potentials firing, which ultimately leads to reduced stimulation of the neurons.	Feeling tired, depressed, drowsiness, dizziness, memory problems, and problems with walking or coordination.	0.5 mg tablet for $278.22 for 100 tablets. 1 mg tablet for $316.06 for 100 tablets. 2 mg tablets for $434.22 for 100 tablets.
Lorazepam	Ativan	IV/IM/PO	No LAI	Lorazepam, often known as ativan, is taken orally. Dosage, frequency of administration, and length of therapy should all be tailored based on patient response for best outcomes. There are 0.5 mg, 1 mg, and 2 mg tablets available to help with this. The daily dosage can range from 1 to 10 mg, although the typical range is 2 to 6 mg given in staggered doses, with the greatest dose taken before sleep. The majority of individuals need an initial dosage for anxiety of two to three milligrams per day administered twice or three times per day. A single daily dose of 2 to 4 mg may be used, usually at bedtime, for sleeplessness brought on by anxiety or momentary situational stress. It is advised to start with divided doses of 1 to 2 mg/day for elderly or disabled individuals, and to increase or decrease the dosage as tolerated.	The recorded half-life of lorazepam when given to parentally is 14 hours. The average elimination half-life of lorazepam was calculated to be 8 hours for oral doses and 11 hours for sublingual doses after 1 mg was administered to healthy adult male volunteers using a multi-doses calculation based on a one-compartment model. For oral dosages, the estimated absorption half-life was 55 minutes, and for sublingual doses, it was 15 minutes.	The FDA has approved lorazepam for the temporary treatment of anxiety symptoms linked to anxiety disorders and anxiety linked to depressive symptoms, such as insomnia brought on by anxiety. In adults, it is often used as a premedication for anesthesia to reduce anxiety, induce drowsiness or forgetfulness, and treat status epilepticus. Rapidly calming an agitated patient, alcohol withdrawal delirium, alcohol withdrawal syndrome, muscle spasms, sleeplessness, panic disorder, delirium, chemotherapy-associated anticipatory nausea and vomiting, and psychogenic catatonia are a few off-label uses for lorazepam.	At several locations throughout the central nervous system (CNS), lorazepam allosterically binds to the benzodiazepine receptors in the post-synaptic GABA-A ligand-gated chloride channel. As a result of this binding, the GABA inhibitory effects will increase, which will increase the flow of chloride ions into the cell, leading the cell to become hyperpolarized and the plasma membrane to stabilize. We may see distinct behaviors based on the lorazepam binding site; the amygdala binding is known to aid mostly with anxiety disorders, whereas the cerebral cortex binding is known to help with seizure disorders.	Weakness, feeling unsteady, drowsiness, dizziness, and sedation.	2mg/ml injectable $59.55 for 25 ml. 0.5 mg tablet 3,5077.77 for 100 tablets. 1mg tablets $4682.77 for 100 tablets.
Others
Diazepam	Valium	IM/IV/PO/Rectal Gel	No LAI	Managing Anxiety Disorders and Relieving Anxiety symptoms 2 mg to 10 mg, twice or four times a day, depending on the severity of symptoms Symptomatic Relief in Acute Alcohol Withdrawal.10 mg, three or four times a day for the first twenty-four hours, then 5 mg, three or four times a day as needed.	Diazepam's action is further prolonged by the even longer half-life of its principal active metabolite, desmethyldiazepam (nordiazepam), of 2–5 days. While desmethyldiazepam (nordiazepam) has a faster initial phase of distribution and a longer terminal elimination phase of 1–2 days, the body's relative proportion of this metabolite increases with prolonged administration.	Diazepam is a fast-acting, long-acting benzodiazepine that is frequently used to treat seizures, severe anxiety, panic attacks, and alcohol withdrawal.	Benzodiazepines like diazepam have sedative, muscle relaxant, anticonvulsant, and amnesic effects. Certain areas of the brain and spinal cord have receptors that benzodiazepines, like diazepam, bind to. Gamma-aminobutyric acid's (GABA) inhibitory actions are amplified by this binding. The CNS is involved in inducing sleep as one of GABA's roles. included in the regulation of neural excitability, hypnosis, memory, anxiety, and epilepsy.	Muscle weakness, feeling tired, drowsiness, and problems with balance or muscle movement.	2 mg oral tablet $623.77. 5mg oral tablet $566.33
Librium	Chlordiazepoxide	PO/IM	No LAI	Managing Moderate to Severe Anxiety Disorders and Their Symptoms5 mg or 10 mg three or four times a day Relieving Severe Anxiety Disorders and Anxiety Symptoms Elderly Patients: 20 mg or 25 mg three or four times a day, or in the event of a crippling illness5 mg two to four times a day Preoperative Fear and Uncertainty: 5 to 10 mg taken orally three or four times a day in the days before surgery. If taken an hour before operation, 50–100 mg intramuscularly (IM).	24-48 hours.	Chlordiazepoxide is prescribed to treat anxiety disorders or to temporarily relieve anxiety symptoms, acute alcoholism withdrawal symptoms, and anxiety and fear before surgery.	Chlordiazepoxide attaches itself to stereospecific BZD binding sites on GABA (A) receptor complexes at many locations in the central nervous system, such as the reticular formation and limbic system. As a result, the inhibitory neurotransmitter GABA binds to the GABA(A) receptor more frequently. Hence, BZDs cause membrane hyperpolarization by amplifying GABA-mediated chloride inflow via GABA receptor channels. The reported sedative, hypnotic, anxiolytic, and muscle relaxant qualities are the outcome of the net neuro-inhibitory actions.	Confusion, balance problems, or drowsiness.	5 mg capsule $16.26 for 60. 10 mg capsule $16.66 for 60 capsules. 25 mg capsule $9.81 for 3 capsules.
Barbiturates
Mephobarbital	Mebaral		No LAI	Adults should take 400–600 mg (6–9 grains) on average per day; children under five years old should take 16–32 mg (1/4 grain to ½ grain) three times a day; children over five years old should take 32–64 mg (½ grain to 1 grain) three times a day.	34 (range 11-67) hours.	Mephobarbital is used as an anticonvulsant to treat epilepsy and to relieve anxiety, tension, and apprehension.	Mephobarbital increases the amount of time that a Cl-ionopore at the GABAA receptor is open by binding at a unique binding site connected to it. This prolongs GABA's post-synaptic inhibitory impact in the thalamus.	Memory or thinking problems, nausea, vomiting, headaches, feeling nervous, dizziness and agitated.	50 powders for reconstitution 500 mg $212.71 per unit. 100 tablets (100 mg) $19.24 per unit totaling $1924.07.
Phenobarbital	Nembutal Sodium	IM/IV/PO	No LAI	Average Adult Sedation Dosage Daytime Sedation: Two or three divided doses of 30 to 120 mg administered orally, intramuscularly, or by IV 400 mg as the maximum dosage in a 24-hour period Prior to Surgery: Intravenously: 100–200 mg 90–60 minutes prior to surgery. Average Adult Dose for Sleeplessness Oral: One daily dose of 100–200 mg is advised. 400 mg is the maximum dosage in a 24-hour period. Parenteral: Dosage recommendations: 100–320 mg IV or IM once daily 400 mg as the maximum dosage in a 24-hour period	5 to 50 hours (dose dependent).	A potent barbiturate and anticonvulsant, phenobarbital is used to treat all forms of seizures, with the exception of absence seizures.	By activating GABAA receptors, phenobarbital increases synaptic inhibition. This has the dual impact of decreasing the spread of seizure activity from a seizure focal and raising the seizure threshold. Additionally, phenobarbital may block calcium channels, which would lessen the release of excitatory transmitters. Phenobarbital's sedative-hypnotic effects are probably due to its action on the polysynaptic midbrain reticular formation, which regulates central nervous system alertness.	Lack of energy, depressed mood, dizziness or spinning sensation, drowsiness, drunk feeling, hangover effect, feeling restless or excited.	65 mg/ml for 3 ml $76.21. 130 mg/ml for 3 ml $458.99.
Amobarbital	Amytal Sodium	IM/IV	No LAI	Adults: a. Sedative: 30 to 50 mg given 2 or 3 times daily. b. Hypnotic: 65 to 200 mg at bedtime.	The half-life in adults ranges between 16 and 40 hours, with a mean of 25 hours.	Amobarbital is a derivative of barbiturates used to treat acute refractory tonic-clonic seizures, short-term insomnia, and induce drowsiness during operations.	Like all barbiturates, amobarbital acts by attaching itself to the alpha or beta subunit of the GABAA receptor. These binding sites are different from both the benzodiazepine binding site and GABA itself. Barbiturates, like benzodiazepines, increase GABA's action at this receptor. The binding of GABAA receptors results in a decrease in input resistance, a reduction in burst and tonic firing, particularly in ventrobasal and intralaminar neurons. Additionally, the mean conductance and burst duration at individual chloride channels are increased, which in turn increases the amplitude and decay time of inhibitory postsynaptic currents. Barbiturates also inhibit the AMPA receptor, a subtype of glutamate receptor, in addition to their GABA-ergic action. The main excitatory neurotransmitter in the mammalian central nervous system is glutamate.	Confusion, hallucinations, headache, anxiety, nausea, slowed breathing, hypotension, and drowsiness.	Injectable powder 500 mg is around $781 for a supply of 1 powder injection.
Secobarbital	Seconal Sodium	PO	No LAI	Average Adult Sedation Dosage Daytime Sedation: Two or three divided doses of 30 to 120 mg administered orally, intramuscularly, or by IV 400 mg as the maximum dosage in a 24-hour period Prior to Surgery: Intravenously: 100–200 mg 90–60 minutes prior to surgery. Average Adult Dose for Sleeplessness Oral: One daily dose of 100–200 mg is advised. 400 mg is the maximum dosage in a 24-hour period. Parenteral: Dosage recommendations: 100–320 mg IV or IM once daily 400 mg as the maximum dosage in a 24-hour period	Children 2 to 13 years: 2.7 to 13.5 hours. Adults 15 to 40 hours, mean: 28 hours.	For the short term, insomnia is treated with the barbiturate secobarbital.	Secobarbital increases the amount of time that a Cl-ionopore at the GABAA receptor is open by binding at a unique binding site connected to it. This prolongs GABA's post-synaptic inhibitory impact in the thalamus.	Headache, dizziness, memory problems, headache, dizziness, upset stomach, drowsiness, feeling tired, hangover effect, dry mouth and feeling excited.	100 quantity $32.27-$37.28

PMHNP Journal for Clinical Practice

Notes:

Last updated: 10/2020 nw

Journal # 8

Substance Use Medication Chart

Generic Name	Trade Name	Route(s) of Administration	LAI Option?	Starting Dose	Half Life	Indications (s/sx & diagnosis)	MOA (neurotransmitter effects)	Side Effects	Costs

Buprenorphine	Belbuca, Brixadi Brprenex Sublocade	Sublingual tablets, buccal films, transdermal films, and IM	Sublocade	Modify dosage in increments or decreases of 2 to 4 mg until the patient remains in therapy and the signs and symptoms of opioid withdrawal are suppressed. The target dosage is 16 mg once daily, sublingually; the range is 4 to 24 mg. The maximum dose is 24 mg per day; there is no therapeutic benefit to greater doses.	Buprenorphine's extended duration of action and its slow dissociation kinetics (~166 min) enable once-daily or even every-second-day treatment. The half-life of sublingually administered buprenorphine/naloxone (2 mg/0.5 mg) was determined to be 30.75 hours in clinical trial trials.	For the treatment of pain that is severe enough to need an opioid analgesic and for which alternative treatments are insufficient, the buccal film, intramuscular or intravenous injection, and transdermal formulation are suggested. For patients who have started treatment with a single dosage of a transmucosal buprenorphine product or who are currently receiving treatment with buprenorphine, extended-release subcutaneous injections are approved for the treatment of moderate to severe opioid use disorder. Injections are a component of a comprehensive treatment program that often includes psychosocial support and counseling. Naloxone, sublingual pills, and buccal films are recommended for the maintenance treatment of opioid dependency as part of a comprehensive treatment approach that also includes psychosocial support and counseling.	When it comes to the mu- and kappa-opioid receptors, buprenorphine functions as a partial agonist and an antagonist, respectively. In comparison to other complete mu-opioid agonists like heroin, oxycodone, or methadone, it has a higher affinity for the mu-opioid receptor but a lower intrinsic activity. This indicates that buprenorphine binds to the opioid receptor preferentially and replaces opioids with lesser affinity while not significantly activating the receptor. From a clinical perspective, this leads to a gradual start of action and a phenomenon called the "ceiling effect," wherein the effects of buprenorphine level off after a particular dosage is reached.	Dizziness, dry mouth, headache, memory loss, orthostatic hypotension, urinary retention, sweating, dry mouth, nausea, vomiting.	2mg – 30 tablets- $14.40 5mcg/hr. transdermal - $311.67 for 4 films
Methadone	Methadose Diskets Dolophine Metadol Methadol-D	PO, IV, IM, Sub-Q, Pareternal	Methadone	Day 1: When withdrawal symptoms are evident, give the first dose under supervision. First dose: 20–30 mg taken orally; if withdrawal symptoms have not been subdued or if symptoms recur, an extra 5–10 mg may be taken orally after 2–4 hours. 30 mg is the maximum starting dose. Maximum dosage for day one: 40 mg Methadone levels will build up over the course of the first few days of dosage, so carefully titrate as needed. During the first week, adjust the dose based on control of withdrawal symptoms at 2 to 4 hours after dosing.	Due to variations in pharmacokinetics across individuals, the half-life of methadone has been estimated to be between 15 and 207 hours, but official monographs mention it between 7 and 59 hours.	When other treatment options are insufficient for a patient's pain that is severe enough to call for an opioid painkiller, methadone is recommended. Additionally, methadone is recommended for the maintenance replacement treatment of adult opioid dependency in conjunction with the proper social and medical services, as well as for the detoxification treatment of opioid addiction (heroin or other narcotics that resemble morphine).	Synthetic opioid analgesic methadone exhibits complete agonist action at the ε-opioid receptor. Methadone functions as an agonist of κ- and σ-opioid receptors in the central and peripheral nervous systems, while agonism of the µ-opioid receptor is the main mode of action for the treatment of pain. Interestingly, methadone is distinct from morphine (which is regarded as the gold standard reference opioid) in that it strongly inhibits the absorption of serotonin and norepinephrine and antagonizes the N-methyl-D-aspartate (NMDA) receptor, which probably also plays a role in methadone's antinociceptive action.	Irregular heartbeat, sleepiness, vomiting, chest pain, dry mouth, loss of appetite, depressed respiratory function, dry. Mouth, constipation, dizziness, diarrhea, blurred vision, sweating, confusion, insomnia, restlessness.	10 mg for $17.00 for a supply of 100. 10 mg/ml $441.04 for 20 ml. Oral concentrate 10 mg/ml $21.26 for 30 ml. Oral solution – 5mg/5ml $16.88 for 150 ml. Oral tablet – 5mg from $10.81 for 100 tablet.
Naltrexone	Contrave Embeda Vivitrol	PO, IM, Sub-Q, IV	Vivatrol	Oral: Dosage: 50 mg once daily by mouth Therapy period: twelve weeks Intramuscular: 380 mg once monthly or every four weeks via injection Orall: First dosage: one daily oral dose of 25 mg Maintenance dosage: 25 mg per day if there are no withdrawals, then 50 mg once daily. Intramuscular: 380 mg once monthly or every four weeks via injection	4 hours for naltrexone and 13 hours for the active metabolite 6 beta-naltrexol.	Naltrexone is used as a supplement to a behavior modification program under medical supervision to help people who were previously physically dependent on opiates and who have successfully completed detoxification stay off of them. Additionally employed in conjunction with a behavioral treatment program to address alcohol abuse.	With minimal to no agonist activity, naltrexone is a pure opiate antagonist. Although the exact mechanism of action of naltrexone in alcoholism is unknown, preclinical evidence points to a possible involvement of the endogenous opioid system. With the highest affinity for the μ receptor, naltrexone is believed to function as a competitive antagonist at the CNS's mc, κ, and δ receptors. Competitively binding to these receptors, naltrexone has the potential to inhibit endogenous opioids' effects. As a result, the majority of opiates' subjective and objective effects—such as euphoria, respiratory depression, miosis, and drug craving—are neutralized. 6-β-naltrexol, the primary metabolite of naltrexone, is likewise an opiate antagonist and might be involved in the drug's antagonistic effects.	Dizziness, headache, sleepiness, decreased appetite, diarrhea, irritability, abdominal pain, vomiting, chills, nervousness, libido disorders, hallucinations, and thirst.	Oral tablet-50 mg $43.43 for 30 tablets.
Acamprosate	Campral	PO	No long acting injectable.	665 mg orally 3 times a day.	Enteric-coated acamprosate tablets show a terminal elimination half-life in pharmacokinetic experiments that is ten times longer than the previously reported 3-hour half-life following intravenous infusion of acamprosate. The terminal half-life of acamprosate 333 mg is 20 to 33 hours following two oral doses.	Acamprosate is used for patients with alcohol dependence who are abstinent at the start of treatment, ambrosia is recommended for maintaining abstinence from alcohol. In patients who have undergone alcohol detoxification, it is also recommended for maintaining alcohol abstinence. When using this medication, a psychosocial support program that offers sufficient assistance should be implemented.	There is no known mechanism of action for acamprosate in maintaining alcohol sobriety. It is thought that long-term alcohol consumption alters the ratio of neural excitation to inhibition. Studies conducted on animals support the idea that acamprosate balances the ratio of neuronal excitation to inhibition by interacting with the glutamate and GABA neurotransmitter systems in the central nervous system. Research indicates that acamprosate affects GABA A receptors indirectly while also directly binding to and inhibiting GABA B receptors.	Dry mouth, diarrhea, dizziness, insomnia, nausea, headache, constipation, depression, loss of appetite, nausea, insomnia, increased urination, abdominal pain, muscle weakness, confusion, weight loss, and sweating.	333 mg oral delayed release tablet-$20.81 for 30 tablets.
Disulfiram	Antabuse	PO	No long acting injectable.	During the initial week or two of treatment, a single dose of up to 500 mg per day is administered. Disulfiram is often given in the morning, however individuals who suffer sedation may take it right before bed. As an alternative, the dosage can be decreased to reduce or completely eliminate the sedative effect. The maintenance dose should not exceed 500 mg per day, with an average of 250 mg (range: 125 to 500 mg).	Disulfiram's half-life in humans is believed to be around 7 hours. Within 3 days, over 90% of DSF is removed, and 7% is expelled through feces and 12% is exhaled.	Disulfiram is used for the treatment and management of chronic alcoholism.	After taking disulfiram, the body accumulates acetaldehyde, which results in extremely unpleasant sensations. This is because disulfiram inhibits the oxidation of alcohol at the acetaldehyde stage of alcohol metabolism. Disulfiram operates in the second step of ethanol usage by irreversibly inactivating aldehyde dehydrogenase, preventing alcohol from being oxidized. Furthermore, disulfiram inhibits and competitively binds to the peripheral benzodiazepine receptor; while this activity has not been thoroughly investigated, it may have some utility in the management of alcohol withdrawal symptoms.	Headache, nausea, drowsiness, chest pain, confusion, decreased sexual ability in males, metallic taste in mouth, flushing, acne, skin rash, blurred vision, eye pain, fainting, sweating, palpitation, mood or mental changes, loss of appetite, thirst, numbness or tingling in extremities.	250 mg oral tablet-$41.36 for 30 tablets. 500 mg oral tablet-$95.84 for 30 tablets.

Substance Use Resources

Commonly Used Drugs and Treatment Information Charts:

https://www.drugabuse.gov/sites/default/files/Commonly-Used-Drugs-Charts_final_June_2020_optimized.pdf

https://www.drugabuse.gov/sites/default/files/nida_commonlyuseddrugs_final_printready.pdf

Withdrawal Sx Chart

https://www.drugabuse.gov/sites/default/files/nida_commonlyabused_withdrawalsymptoms_10062017-508-1.pdf