Psychotropic Side Effects Library

Selective Serotonin Reuptake Inhibitors (SSRIs)

Sertraline · Escitalopram · Fluoxetine · Paroxetine · Citalopram · Fluvoxamine

Sertraline (Zoloft)

SSRI Black Box

▼

Side Effect Profile

Severity	Side Effect	Onset / Notes
Common	Nausea, diarrhea, loose stools	Early; usually resolves weeks 2–4
Common	Sexual dysfunction (delayed orgasm, decreased libido, ED)	Persistent; affects up to 40–60%
Common	Insomnia or somnolence	Dose-dependent; take AM if activating
Common	Headache, tremor	Early onset; typically transient
Common	Sweating (diaphoresis)	Nocturnal sweating common
Common	Weight gain (long-term)	Average +1–2 kg/year
Serious	Serotonin syndrome	Risk with triptans, MAOIs, tramadol, linezolid
Serious	Suicidality (age <24)	Black Box Warning — monitor closely first 4 weeks
Serious	GI bleeding risk	Especially with NSAIDs or anticoagulants
Serious	Hyponatremia (SIADH)	Elderly at highest risk; check Na if mental status changes
Serious	Activation/mania in bipolar	Screen before prescribing; use mood stabilizer first
Rare	Angle-closure glaucoma	Serotonin-mediated pupil dilation; refer ophthalmology
Rare	Seizures	Low risk at therapeutic doses

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (age <24): Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults. Monitor for worsening depression, suicidality, or unusual changes in behavior especially during the first 1–4 weeks and after dose changes. Not approved for children except for OCD (≥6 years).

Monitoring Schedule

Baseline

Weight, suicidality screen, mood, sexual function inquiry

Week 1–2

Phone/portal check — tolerability, activation, GI sx

Week 4

Efficacy check, side effect review, suicidality screen

Week 8

Full response assessment; consider dose adjustment

Every 3–6 mo

Weight, sexual function, mood, adherence

Na (elderly)

BMP at baseline and 2–4 weeks; PRN if mental status Δ

Key Drug Interactions

MAOIsContraindicated — severe serotonin syndrome risk. 14-day washout required.

Linezolid / Methylene BlueSerotonin syndrome risk — avoid combination.

TramadolSerotonin syndrome + lowers seizure threshold.

NSAIDs / AspirinIncreased GI bleeding risk; consider PPI if chronic NSAID use.

Warfarin / DOACsIncreased bleeding; monitor INR; sertraline is CYP2C9 inhibitor.

TriptansTheoretical serotonin syndrome — monitor; benefit usually outweighs risk.

LithiumMonitor for serotonin syndrome; no dose change usually needed.

Pregnancy / Lactation

Pregnancy:Category C (ACOG: generally acceptable if benefit > risk)

Lactation:Low infant exposure; generally preferred SSRI in breastfeeding

PPHN Risk: Late pregnancy use associated with persistent pulmonary hypertension of the newborn (PPHN) — counsel and monitor neonates exposed in 3rd trimester.

Renal / Hepatic Dosing

Renal Impairment

No dose adjustment required for mild–moderate CKD. Use caution in severe renal disease.

Hepatic Impairment

Reduce dose by 50%; use lower end of range. Avoid in severe hepatic failure.

📋 Counseling Dot Phrase

.SERTRALINECOUNSEL
Discussed initiation of sertraline [DOSE] mg PO daily for [DIAGNOSIS].

BENEFITS: Reduction in [depression symptoms/anxiety/OCD symptoms]. 
Full therapeutic effect expected in 4–8 weeks. Initial partial response 
may occur sooner. Long-term maintenance reduces relapse risk.

SIDE EFFECTS REVIEWED:
- GI effects (nausea, diarrhea) common early, usually resolve by weeks 2–4; 
  recommend taking with food
- Sexual side effects: decreased libido, delayed orgasm — persistent in some; 
  management options available if problematic
- Insomnia or fatigue: take in AM if activating, PM if sedating
- Weight changes possible with long-term use
- Headache, tremor, sweating early in course

SERIOUS RISKS DISCUSSED:
- Serotonin syndrome: avoid concurrent use of MAOIs, tramadol, triptans 
  without provider guidance; recognize symptoms (agitation, tremor, fever)
- Bleeding risk increased when combined with NSAIDs/aspirin/blood thinners
- Worsening mood or suicidal thoughts — call immediately if this occurs
- Mood elevation (hypomania/mania) — notify immediately

PATIENT INSTRUCTIONS: 
- Do not stop abruptly; taper under guidance to avoid discontinuation syndrome
- Allow 4–8 weeks before full assessment of benefit
- Avoid alcohol (worsens CNS effects)
- Safe to take if dose missed — do not double next dose

Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Escitalopram (Lexapro)

SSRIBlack Box

▼

Side Effect Profile

Severity	Side Effect	Notes
Common	Nausea, dry mouth	GI effects milder than other SSRIs
Common	Sexual dysfunction	Common; often underreported — ask directly
Common	Somnolence or insomnia	Can be activating or sedating — individualize
Common	Hyperhidrosis	Nocturnal more than daytime
Serious	QTc prolongation	Dose-dependent; max 20 mg/day (10 mg/day in elderly/hepatic)
Serious	Serotonin syndrome	With MAOIs, linezolid, methylene blue
Serious	Hyponatremia (SIADH)	Elderly, females, concurrent diuretics
Serious	Suicidality in <24yo	Black Box Warning

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (age <24). Additionally: QTc prolongation is dose-dependent — do not exceed 20 mg/day (10 mg/day in elderly or hepatic impairment). Obtain baseline EKG in patients with known cardiac disease, electrolyte abnormalities, or concurrent QT-prolonging medications.

Monitoring

Baseline

EKG (if cardiac hx or concurrent QT drugs), weight, labs

Ongoing

Same as sertraline; EKG PRN if dose escalated or cardiac concern

Elderly

Max dose 10 mg; Na check at 2 weeks

Key Interactions

QT-prolonging agentsAntiarrhythmics, antipsychotics, antimalarials — additive QTc risk; review EKG.

MAOIsContraindicated — serotonin syndrome.

CimetidineIncreases escitalopram levels by CYP2C19 inhibition.

Pregnancy / Lactation

Pregnancy:Category C — generally acceptable; neonatal withdrawal with 3rd trimester use

Lactation:Low relative infant dose; acceptable with monitoring

Renal

No adjustment needed mild–moderate CKD.

Hepatic

Max 10 mg/day; half the standard dose.

📋 Counseling Dot Phrase

.ESCITALOPRAMCOUNSEL
Discussed initiation of escitalopram [DOSE] mg PO daily for [DIAGNOSIS].

KEY POINTS:
- Best-tolerated SSRI for many patients; fewer drug interactions than others
- Sexual side effects common — please report; options exist to manage
- QTc prolongation is dose-related; do not take more than prescribed
- Avoid concurrent OTC QT-prolonging medications without checking first
- Do not stop abruptly; taper under guidance

Serotonin syndrome risk discussed. Instructions for emergency contact given.
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Fluoxetine (Prozac, Sarafem)

SSRIBlack Box

▼

Unique Pharmacology

Long half-life (1–6 days + active metabolite norfluoxetine 4–16 days): Provides built-in taper on discontinuation — lower discontinuation syndrome risk. However, drug interactions persist for weeks after stopping. 5-week washout before MAOI.

Severity	Side Effect	Notes
Common	Activation, insomnia, anxiety	More activating than other SSRIs; take AM
Common	Nausea, decreased appetite	May cause initial weight loss
Common	Sexual dysfunction	Equal to other SSRIs
Common	Headache, tremor	Typically resolves
Serious	Serotonin syndrome	Long half-life extends interaction window
Serious	Suicidality in <24yo	Black Box Warning; approved for pediatric depression/OCD
Serious	Drug interactions	Strong CYP2D6 inhibitor — see interactions below
Rare	Rash (1–4%)	Discontinue and evaluate if rash develops

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (<24 years). 5-week washout required before starting MAOI due to long half-life of fluoxetine and norfluoxetine.

Key Drug Interactions (Strong CYP2D6 Inhibitor)

TamoxifenBlocks conversion to active metabolite endoxifen — reduces efficacy in breast cancer. Avoid.

TCAsSignificantly increases TCA levels — toxicity, cardiac risk. Dose reduce TCA markedly.

Codeine / TramadolBlocks conversion to active metabolites; reduces analgesia and increases seizure risk.

AntipsychoticsIncreases levels of risperidone, aripiprazole, haloperidol via CYP2D6 inhibition.

Beta-blockersIncreases metoprolol, propranolol levels — bradycardia, hypotension.

Renal

No adjustment needed; active metabolite prolonged in severe CKD — use lower doses.

Hepatic

Reduce dose; half-life extended. Use every-other-day dosing in cirrhosis.

📋 Counseling Dot Phrase

.FLUOXETINECOUNSEL
Discussed initiation of fluoxetine [DOSE] mg PO daily for [DIAGNOSIS].

UNIQUE PROPERTIES DISCUSSED:
- Very long half-life means it builds up and stays in system 4–6 weeks after stopping
- Lower discontinuation syndrome risk vs. other antidepressants
- More activating than other SSRIs — take in the morning; may initially 
  increase anxiety or insomnia
- Weight loss possible early; weight gain with long-term use

DRUG INTERACTIONS:
- Do not start MAOIs for 5 weeks after stopping fluoxetine
- Informs prescribers before starting any new medications; fluoxetine 
  affects many drugs through liver enzymes
- Avoid codeine-containing products (reduced pain relief)

Side effects, risks (suicidality in <24yo, serotonin syndrome, bleeding) reviewed.
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Paroxetine (Paxil, Paxil CR)

SSRIBlack Box

▼

⚠ Highest discontinuation syndrome risk of all SSRIs. Shortest half-life (~21h), no active metabolite. Highest anticholinergic burden of SSRIs — use with caution in elderly.

Severity	Side Effect	Notes
Common	Sedation, fatigue	Most sedating SSRI — take at bedtime
Common	Weight gain	Highest weight gain of SSRIs; anticholinergic-mediated appetite increase
Common	Sexual dysfunction	Highest rate of all SSRIs — discuss early
Common	Dry mouth, constipation, urinary retention	Anticholinergic effects
Common	Discontinuation syndrome	"Brain zaps," dizziness, flu-like on abrupt stop — taper slowly
Serious	Suicidality in <24yo	Black Box Warning
Serious	Neonatal effects / Teratogenicity	Category D — associated with cardiac defects; prefer alternative in pregnancy
Serious	Serotonin syndrome, hyponatremia, bleeding	Class effects

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (<24 years). Pregnancy Category D — cardiac defects (atrial/ventricular septal defects) reported with 1st trimester use. Persistent pulmonary hypertension of newborn with 3rd trimester use. Avoid in pregnancy if alternatives exist.

Renal

CrCl <30: start 10 mg/day, max 40 mg/day.

Hepatic

Severe: start 10 mg/day, max 40 mg/day. Use caution.

📋 Counseling Dot Phrase

.PAROXETINECOUNSEL
Discussed initiation of paroxetine [DOSE] mg PO [daily/nightly] for [DIAGNOSIS].

KEY COUNSELING POINTS:
- Take at bedtime — more sedating than other antidepressants in class
- Higher risk of weight gain compared to other SSRIs
- Higher rate of sexual side effects — please report; alternatives available
- CRITICAL: Do NOT stop abruptly — causes severe discontinuation syndrome 
  (dizziness, "brain zaps," flu-like, crying spells). Must taper slowly.
- Not preferred in pregnancy — discuss contraception and pregnancy plans

ANTICHOLINERGIC EFFECTS: May cause dry mouth, constipation, blurred vision, 
urinary hesitancy — especially problematic in older adults.

Standard SSRI risks reviewed (suicidality, serotonin syndrome, bleeding, hyponatremia).
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Citalopram (Celexa)

SSRIBlack Box

▼

⚠ QTc Prolongation — FDA Dosing Restriction (2011): Maximum dose 40 mg/day. Maximum 20 mg/day in: patients >60 years, hepatic impairment, CYP2C19 poor metabolizers, concurrent CYP2C19 inhibitors (omeprazole, cimetidine).

Severity	Side Effect	Notes
Common	Nausea, dry mouth, sweating	Class effects
Common	Somnolence or insomnia	Variable — individualize timing
Common	Sexual dysfunction	Common class effect
Serious	QTc prolongation → Torsades de Pointes	Dose-dependent; obtain EKG in high-risk patients
Serious	Hyponatremia, serotonin syndrome	Class effects
Serious	Suicidality in <24yo	Black Box Warning

⚠ FDA Black Box Warning + QTc Warning

Suicidality in pediatric/young adult (<24). QTc dosing restrictions: Max 40 mg/day universally. Max 20 mg/day in patients >60yo, CYP2C19 poor metabolizers, or taking CYP2C19 inhibitors. Obtain baseline EKG in cardiac patients, with electrolyte imbalances, or concurrent QT-prolonging drugs.

📋 Counseling Dot Phrase

.CITALOPRAMCOUNSEL
Discussed initiation of citalopram [DOSE] mg PO daily for [DIAGNOSIS].

SPECIAL CARDIAC COUNSELING:
- This medication can affect heart rhythm at higher doses
- Do not take more than prescribed; do not take extra doses
- Maximum dose is [20/40] mg/day based on your [age/liver function/medications]
- Report palpitations, racing heart, dizziness, fainting immediately
- Avoid other medications that affect heart rhythm without discussing first
  (some antihistamines, antibiotics, antifungals)

Standard SSRI side effects and risks reviewed.
EKG [obtained at baseline / ordered / reviewed] — [results].
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Fluvoxamine (Luvox, Luvox CR)

SSRIBlack Box

▼

Primary indication: OCD (adults and children ≥8yo). Also used for social anxiety, PTSD. Sigma-1 receptor activity — studied in COVID-19. Most complex drug interactions of SSRIs due to CYP1A2, CYP2C19, CYP3A4 inhibition.

Severity	Side Effect	Notes
Common	Nausea (most common SE)	High rate of nausea — take with food, start low
Common	Somnolence, fatigue	More sedating than other SSRIs
Common	Sexual dysfunction, insomnia	Class effects
Serious	Multiple drug interactions	Inhibits CYP1A2, CYP2C19, CYP3A4 — extensive interaction profile
Serious	Suicidality in <24yo	Black Box Warning

Key Drug Interactions (CYP1A2 + CYP3A4 Inhibitor)

Clozapine / OlanzapineDramatically increases levels — use only with extreme caution; requires dose reduction.

TheophyllineIncreases theophylline levels 3×; toxicity risk.

TizanidineContraindicated — severe hypotension, CNS depression.

WarfarinIncreases INR significantly — monitor closely.

Alprazolam / TriazolamIncreases benzo levels; increase sedation risk.

📋 Counseling Dot Phrase

.FLUVOXAMINECOUNSEL
Discussed initiation of fluvoxamine [DOSE] mg PO [daily/BID] for [OCD/Social Anxiety].

IMPORTANT DRUG INTERACTION WARNING:
- Fluvoxamine affects many liver enzymes and interacts with numerous 
  medications. Always check with me or pharmacy before starting any 
  new medication, including supplements.
- Notable interactions: blood thinners, seizure medications, some 
  antibiotics, muscle relaxants, certain sleep aids

NAUSEA: Common early on; take with food; usually improves.
SEDATION: Take larger dose at bedtime if divided dosing prescribed.

Standard SSRI risks reviewed (suicidality in <24yo, serotonin syndrome, bleeding).
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Venlafaxine · Duloxetine · Desvenlafaxine · Levomilnacipran

Venlafaxine (Effexor, Effexor XR)

SNRIBlack Box

▼

Dose-dependent NE activity: At ≤75 mg/day, primarily serotonergic (SSRI-like). Norepinephrine effects increase at higher doses (>150 mg). Full dual action at ≥225 mg. This affects BP monitoring thresholds and side effect profile.

Severity	Side Effect	Notes
Common	Nausea, vomiting	High rate early; take with food; usually resolves
Common	Sexual dysfunction	Equivalent to SSRIs
Common	Hypertension	Dose-dependent NE effect; check BP at baseline and follow-up
Common	Tachycardia	Dose-related; monitor HR
Common	Sweating, dry mouth	Noradrenergic effects
Common	Insomnia, headache	Activating
Serious	Discontinuation syndrome	Severe — "electric shocks," dizziness, irritability. Must taper slowly. Second worst after paroxetine.
Serious	Hypertension	Sustained elevations at higher doses — monitor BP
Serious	Suicidality in <24yo	Black Box Warning
Serious	Serotonin syndrome, hyponatremia, bleeding	Class effects

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (<24 years). Blood pressure monitoring required — dose-related hypertension especially at >150 mg/day. Severe discontinuation syndrome — never stop abruptly.

Baseline

BP, HR, weight

Every visit

BP check (especially with dose changes)

Elderly

Na check at 2 weeks; fall risk

📋 Counseling Dot Phrase

.VENLAFAXINECOUNSEL
Discussed initiation of venlafaxine XR [DOSE] mg PO daily for [DIAGNOSIS].

BLOOD PRESSURE MONITORING:
- This medication can raise blood pressure, especially at higher doses
- Monitor BP at home if possible; report readings consistently >130/80
- BP [baseline today: ____]

DISCONTINUATION SYNDROME — CRITICAL:
- Do NOT stop abruptly or miss multiple doses
- Discontinuation causes severe withdrawal: dizziness, "brain zaps," 
  nausea, irritability, flu-like symptoms
- Always taper slowly under medical guidance; may take weeks-months

Nausea common early — take with food; usually resolves in 1–2 weeks.
Sexual side effects possible — please report.
Higher doses provide additional benefit for pain/anxiety via NE pathway.

Standard SNRI risks reviewed (suicidality, serotonin syndrome, bleeding).
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Duloxetine (Cymbalta)

SNRIBlack Box

▼

FDA indications: MDD, GAD, fibromyalgia, diabetic peripheral neuropathic pain, chronic musculoskeletal pain. Balanced SNRI from low doses.

Severity	Side Effect	Notes
Common	Nausea, constipation, dry mouth	GI effects common; take with food
Common	Fatigue or insomnia	Variable
Common	Sexual dysfunction, sweating	NE + serotonin effects
Common	Hypertension	Less than venlafaxine; still monitor
Serious	Hepatotoxicity	Rare but cases of liver failure reported; avoid in heavy alcohol use or hepatic disease
Serious	Discontinuation syndrome	Severe — avoid abrupt stop; taper required
Serious	Suicidality in <24yo	Black Box Warning
Serious	Urinary hesitancy	NE effect; problematic in BPH

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (<24 years). Hepatotoxicity warning: Avoid in patients with hepatic impairment or substantial alcohol use. Serious liver injury, including fatal cases, has been reported rarely.

Renal

Avoid if CrCl <30 mL/min. Use with caution in moderate CKD.

Hepatic

Avoid in hepatic impairment (any significant degree). Contraindicated in cirrhosis.

📋 Counseling Dot Phrase

.DULOXETINECOUNSEL
Discussed initiation of duloxetine [DOSE] mg PO daily for [DIAGNOSIS / Pain indication].

BENEFITS: Dual action on depression AND pain — useful for fibromyalgia, 
nerve pain, chronic musculoskeletal pain in addition to mood/anxiety.

LIVER SAFETY:
- Avoid more than 1 alcoholic drink per day — duloxetine and alcohol 
  together can stress the liver
- Report yellow skin/eyes, dark urine, severe right-sided abdominal pain

DO NOT STOP ABRUPTLY: Severe discontinuation syndrome. Taper required.

BP and urinary side effects discussed. Sexual side effects reviewed.
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Desvenlafaxine (Pristiq) / Levomilnacipran (Fetzima)

SNRIBlack Box

▼

Desvenlafaxine: Active metabolite of venlafaxine. Fixed dose (50 mg/day standard). Fewer drug interactions. Do not crush/chew extended-release tablet. Similar side effect profile to venlafaxine.

Levomilnacipran: Most norepinephrine-selective SNRI (3:1 NE:5-HT ratio). May have more BP/HR effects. Used for MDD. Once daily ER formulation.

Medication	Key Differences from Venlafaxine
Desvenlafaxine	No CYP2D6 inhibition — fewer drug interactions; fixed-dose; same SE profile
Levomilnacipran	More NE-selective; higher rate tachycardia/BP changes; urinary retention risk higher

📋 Counseling Dot Phrase (Desvenlafaxine)

.DESVENLAFAXINECOUNSEL
Discussed initiation of desvenlafaxine [50/100] mg PO daily for [DIAGNOSIS].

- Swallow tablet whole — do not crush, chew, or split
- Similar to Effexor (venlafaxine) but fewer drug interactions
- Same BP monitoring, discontinuation, and sexual side effect profile
- Do NOT stop abruptly — taper required

BP baseline: [___]. Monitoring plan: [___].
Standard SNRI risks reviewed. Patient verbalized understanding.
[Agreed to proceed / Declined].

Atypical Antidepressants

Bupropion · Mirtazapine · Trazodone · Vilazodone · Vortioxetine

Bupropion (Wellbutrin SR/XL, Zyban)

NDRIBlack Box

▼

Mechanism: NE + dopamine reuptake inhibition (NDRI). No serotonin activity — no sexual side effects, no serotonin syndrome. Weight neutral to weight loss. Also FDA-approved for smoking cessation.

Severity	Side Effect	Notes
Common	Insomnia, activation, anxiety	Activating — avoid PM dosing; take AM
Common	Dry mouth, headache	Common early; typically resolves
Common	Tachycardia, hypertension	Noradrenergic; monitor BP/HR
Common	Decreased appetite, weight loss	Often beneficial; monitor if underweight
Serious	SEIZURE RISK	Dose-dependent. Risk highest with IR formulation; max single dose 150 mg IR, 200 mg SR, 450 mg XL. Contraindicated in seizure disorders.
Serious	Suicidality in <24yo / neuropsychiatric for smoking	Black Box Warning (both indications)
Serious	Psychosis or mania	Dopaminergic stimulation — screen bipolar; may precipitate mania
Rare	Anaphylactic reaction to bupropion	Very rare; serum sickness-like reaction

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (<24 years) — antidepressant indication
Neuropsychiatric events with smoking cessation (Zyban): mood, behavior, hostility, depression, suicidal ideation
Seizure risk is dose-dependent: Contraindicated in seizure disorder, current/recent bulimia or anorexia (lowers seizure threshold), abrupt alcohol/benzo discontinuation

Seizure Contraindications

Avoid bupropion in: History of seizures, bulimia/anorexia nervosa (active or recent), abrupt benzodiazepine/alcohol discontinuation, head trauma with seizure risk, patients on other medications that lower seizure threshold (tramadol, antipsychotics at high doses). Maximum single dose must be respected regardless of total daily dose.

Renal

Reduce dose in severe CKD. Use lowest effective dose.

Hepatic

Severe cirrhosis: max 75 mg/day IR or 100 mg SR every other day.

📋 Counseling Dot Phrase

.BUPROPIONUCOUNSEL
Discussed initiation of bupropion [150/300/450] mg [SR/XL] PO daily for [DIAGNOSIS].

ADVANTAGES FOR THIS PATIENT:
- No sexual side effects (unique benefit vs. SSRIs/SNRIs)
- Weight neutral to weight loss effect
- May improve energy, concentration, motivation
- Smoking cessation benefit if applicable

SEIZURE RISK — CRITICAL SAFETY:
- Do NOT take more than the prescribed dose at one time
- Do NOT take at bedtime or more frequently than prescribed
- Do NOT use recreational drugs, alcohol excessively, or stop 
  anxiety medication abruptly — this increases seizure risk
- Inform all providers you take bupropion before they prescribe
  tramadol, seizure medications, or antipsychotics

ACTIVATION: Take all doses before 5 PM to avoid insomnia.
May feel more anxious or energized early on — usually settles.

Suicidality risk discussed. Bipolar screening completed: [negative/pending].
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Mirtazapine (Remeron)

NaSSABlack Box

▼

Mechanism: α2 antagonist + 5-HT2/5-HT3 antagonist + H1 antagonist. Paradox: lower doses (7.5–15 mg) are MORE sedating due to greater H1 blockade; higher doses (30–45 mg) are more activating due to added NE effects. Ideal for depression with insomnia or low appetite/weight loss.

Severity	Side Effect	Notes
Common	Weight gain (significant)	Average +2–4 kg; 5-HT2C + H1 blockade stimulates appetite. Counsel at start.
Common	Sedation (strong)	Highest sedation of antidepressants; take at bedtime; therapeutic for insomnia
Common	Increased appetite, carbohydrate craving	Mechanism-related
Common	Dry mouth, constipation	Anticholinergic-like (via H1/α effects)
Serious	Agranulocytosis / neutropenia	Rare but documented; monitor CBC if fever/sore throat develops
Serious	Suicidality in <24yo	Black Box Warning
Rare	Restless legs syndrome	Can worsen or precipitate RLS
Rare	Hypertriglyceridemia	Monitor fasting lipids long-term

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (<24 years). Report fever, chills, sore throat — may indicate agranulocytosis.

📋 Counseling Dot Phrase

.MIRTAZAPINECOUNSEL
Discussed initiation of mirtazapine [7.5/15/30/45] mg PO qHS for [DIAGNOSIS].

TARGET BENEFITS: Depression treatment + sleep improvement + appetite 
stimulation [select as applicable].

WEIGHT GAIN — SET EXPECTATIONS:
- Significant weight gain is expected — average 2–4 kg or more
- Appetite and carbohydrate cravings increase — proactive diet awareness helpful
- This is a reason to stop the medication for some patients; discuss early

SEDATION: Take ONLY at bedtime — causes significant drowsiness.
Do not drive until you know how it affects you. Paradoxically, lower 
doses (7.5–15 mg) may be MORE sedating than 30–45 mg.

AGRANULOCYTOSIS (rare): Call if you develop fever, sore throat, mouth 
ulcers — we may need urgent blood work.

No sexual side effects. Does not interact with serotonin — lower serotonin 
syndrome risk compared to other antidepressants.

Standard antidepressant risks reviewed. 
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Trazodone (Desyrel, Oleptro)

SARIBlack Box

▼

Use pattern: Rarely used as a primary antidepressant (low antidepressant doses). Widely used off-label as a sleep aid at low doses (25–100 mg qHS) — not FDA-approved for insomnia but common practice. Low abuse potential.

Severity	Side Effect	Notes
Common	Sedation (next-day grogginess)	Strong sedation — take immediately before bed; next-morning impairment
Common	Orthostatic hypotension, dizziness	α1 blockade — fall risk especially in elderly; rise slowly
Common	Dry mouth, blurred vision	Anticholinergic-like effects
Serious	Priapism	Rare but medical emergency — painful erection >4h requires ER visit. Risk highest at low doses. Counsel ALL male patients.
Serious	QTc prolongation	At antidepressant doses; obtain EKG in high-risk patients
Serious	Suicidality in <24yo	Black Box Warning
Serious	Serotonin syndrome	With MAOIs, SSRIs, SNRIs — lower risk than SSRIs but real

⚠ FDA Black Box Warning + Priapism Warning

Suicidality in pediatric/young adult (<24). PRIAPISM: Painful sustained erections have been reported. Patients who develop erections lasting >4 hours should seek immediate ER care. This is a surgical emergency if untreated. Counsel all male patients prior to prescribing.

📋 Counseling Dot Phrase

.TRAZODONECOUNSEL
Discussed initiation of trazodone [25/50/100] mg PO qHS for [Insomnia / Depression].

PURPOSE: [Sleep aid / Antidepressant — note if off-label for insomnia].

PRIAPISM WARNING (Male patients):
- Rare but serious risk: painful erections lasting longer than 4 hours
- This is a medical emergency — go to the ER immediately if it occurs
- Do not ignore or wait — untreated priapism can cause permanent damage
- Risk present especially at lower doses

SEDATION: Strong — take immediately before bedtime. Do not drive after 
taking. May have next-morning grogginess (especially at higher doses).

DIZZINESS/FALLS: May cause low blood pressure and dizziness on standing — 
rise slowly from sitting/lying; avoid at night bathroom trips without 
steadying first (fall risk).

Non-habit-forming. No sexual side effects (may even improve with antidepressant use).
Interactions reviewed. Standard antidepressant risks discussed.
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Vilazodone (Viibryd) / Vortioxetine (Trintellix)

MultimodalBlack Box

▼

Feature	Vilazodone (Viibryd)	Vortioxetine (Trintellix)
Mechanism	SSRI + 5-HT1A partial agonist	SSRI + 5-HT1A agonist + 5-HT3/1D/7 antagonist
Cognitive effect	Modest	FDA-approved for cognitive symptom improvement
Sexual side effects	Potentially lower	Lower rate than SSRIs
GI effects	High nausea — take WITH food (required)	Nausea common early; take with food
Titration	10 mg × 7d → 20 mg × 7d → 40 mg	Start 10 mg; may ↑ to 20 mg
Drug interactions	CYP3A4 substrate	Strong CYP2D6 inhibitors double level — max 10 mg
BBW	Suicidality <24yo	Suicidality <24yo

📋 Counseling Dot Phrase (Vortioxetine)

.VORTIOXETINECOUNSEL
Discussed initiation of vortioxetine [10/20] mg PO daily for [MDD].

BENEFITS: Antidepressant effects PLUS cognitive improvement 
(memory, concentration, processing speed) — unique in this class.

GI: Nausea common early — take with food; usually resolves in 1–2 weeks.
Sexual side effects: Lower rate than typical antidepressants.

DRUG INTERACTION: If you start strong CYP2D6 inhibitors (bupropion, 
fluoxetine, paroxetine), dose may need reduction. Alert all providers.

Standard antidepressant risks reviewed (suicidality, serotonin syndrome).
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Tricyclic Antidepressants (TCAs)

Amitriptyline · Nortriptyline · Desipramine · Imipramine

Class Warning: TCAs are highly lethal in overdose. A 2-week supply can be fatal. Consider limiting dispensing (1-week supplies) in patients with suicidality. Anticholinergic burden is high — avoid in elderly (Beers Criteria), BPH, glaucoma. Cardiac effects require baseline EKG.

Tricyclic Antidepressants — Class Overview

TCABlack Box

▼

Drug	Tertiary/Secondary	Sedation	Anticholinergic	Orthostasis	Preferred Use
Amitriptyline	Tertiary	High	High	High	Neuropathic pain, migraine prophylaxis (low dose)
Imipramine	Tertiary	Moderate	High	High	Enuresis, panic disorder
Nortriptyline	Secondary	Moderate	Moderate	Low	Better-tolerated TCA; smokers (cessation)
Desipramine	Secondary	Low	Low	Low	Least sedating/anticholinergic TCA

Side Effects — All TCAs

Severity	Side Effect	Notes
Common	Anticholinergic: dry mouth, constipation, urinary retention, blurred vision, confusion	Higher in tertiary amines; severe in elderly
Common	Sedation	Highest with amitriptyline; use at bedtime
Common	Orthostatic hypotension, dizziness	Fall risk; α1 blockade
Common	Weight gain	Common with all TCAs
Common	Sexual dysfunction	Common class effect
Serious	Cardiac: QTc prolongation, heart block, arrhythmia	Sodium channel blockade; baseline EKG required; avoid in post-MI, bundle branch block
Serious	Overdose lethality	Therapeutic index narrow; 1–2g can be fatal; limit dispensing quantity in high-risk
Serious	Lowered seizure threshold	Risk increases with dose
Serious	Suicidality in <24yo	Black Box Warning
Rare	Agranulocytosis, hepatitis	Monitor if fever or jaundice

⚠ FDA Black Box Warning

Suicidality in pediatric/young adult patients (<24 years). OVERDOSE LETHALITY: TCAs are among the most dangerous medications in overdose. Consider limiting dispensing to ≤1-week supply in patients with any suicidal ideation. A single day's supply (at antidepressant doses) can be lethal. Mandatory EKG before initiation and with dose increases.

Baseline EKG

Required — QTc, PR interval, bundle branch block

Drug levels

Nortriptyline: therapeutic 50–150 ng/mL. Useful for efficacy and toxicity monitoring.

BP standing

Orthostatic BP at baseline; each visit

Cognitive (elderly)

MMSE or MoCA baseline — anticholinergic burden

📋 Counseling Dot Phrase

.TCACOUNSEL
Discussed initiation of [amitriptyline/nortriptyline/desipramine] [DOSE] mg 
PO [qHS/daily] for [Diagnosis/Neuropathic pain/Migraine prophylaxis].

OVERDOSE WARNING — DISCUSSED EXPLICITLY:
- This medication is VERY dangerous in overdose — even a few extra doses 
  can be life-threatening
- Keep medication locked up and away from children
- Do not leave extra doses accessible [pill safe recommended if high-risk]
- Call 911 or go to ER immediately if overdose suspected

CARDIAC MONITORING: EKG obtained [date] — [results]. Must be taken at doses 
prescribed; do not increase on your own.

ANTICHOLINERGIC EFFECTS: Dry mouth, constipation, blurred vision, difficulty 
urinating — common. Report severe urinary retention immediately.

DIZZINESS: Rise slowly from bed/chair. Bedtime dosing helps with sedation 
effect; may be therapeutic for insomnia and pain.

Do not stop abruptly — taper under guidance.
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Antipsychotics — Second Generation (SGAs)

Quetiapine · Aripiprazole · Risperidone · Olanzapine · Ziprasidone · Lurasidone · Cariprazine · Brexpiprazole

SGA Class Overview — Metabolic & Safety Comparison

SGABlack Box

▼

⚠ FDA Black Box Warning — ALL Antipsychotics

Elderly with dementia-related psychosis: Increased mortality risk (1.6–1.7× higher). Antipsychotics are NOT approved for dementia-related psychosis.
Suicidality in young adults: When used for depression augmentation

Metabolic Syndrome Risk Comparison

SGA	Weight Gain	Glucose↑	Lipids↑	QTc	EPS Risk	Prolactin	Sedation
Olanzapine	Very High	High	High	Low	Low	Moderate	High
Clozapine	Very High	High	High	Moderate	Low	Low	Very High
Quetiapine	High	Moderate	Moderate	Moderate	Low	Low	High
Risperidone	Moderate	Moderate	Moderate	Moderate	Moderate	High	Moderate
Ziprasidone	Low	Low	Low	High	Low	Low	Moderate
Aripiprazole	Low	Low	Low	Low	Low	Low	Low
Lurasidone	Low	Low	Low	Low	Moderate	Moderate	Moderate
Cariprazine	Low	Low	Low	Low	Low	Low	Low
Brexpiprazole	Moderate	Low	Low	Low	Low	Low	Low

Metabolic Monitoring Schedule (AIMS + Metabolic Panel)

Baseline

Weight/BMI, waist circumference, BP, fasting glucose, fasting lipids, HbA1c, AIMS exam

4 Weeks

Weight, BP

8 Weeks

Weight, BP, fasting glucose

12 Weeks

Weight, BP, fasting glucose, fasting lipids, AIMS

Every 6 Months

Weight, BP, fasting glucose; AIMS every 6 months

Annually

Full metabolic panel, HbA1c, lipids, AIMS

EPS / TD Risk and Management

Tardive Dyskinesia (TD): Cumulative risk ~5% per year with FGAs; lower with SGAs. Risk highest with high-dose, long-term antipsychotic use, older age, female sex, African American ethnicity, early EPS. AIMS exam every 6 months — document score. If TD detected, consider dose reduction, switch to lower-risk agent, or VMAT2 inhibitor (valbenazine, deutetrabenazine). KINECT trial evidence.

Quetiapine (Seroquel, Seroquel XR)

SGABlack Box

▼

Wide indications: Schizophrenia, bipolar I mania, bipolar depression, MDD augmentation (XR), generalized anxiety (off-label). Sedation is dose-dependent. Low EPS risk. Low prolactin elevation.

Severity	Side Effect	Notes
Common	Sedation (often significant)	Greatest at low doses (25–100 mg); widely used for insomnia off-label
Common	Weight gain, increased appetite	Moderate-high risk; counsel at initiation
Common	Orthostatic hypotension, dizziness	α1 blockade; especially early in treatment
Common	Dry mouth, constipation	Anticholinergic-like effects
Serious	Metabolic syndrome	Monitor per schedule above
Serious	QTc prolongation	Moderate risk; avoid with concurrent QT drugs
Serious	Cataracts	Rare; ophthalmologic exam at 6 months recommended per label
Serious	Elderly mortality (dementia)	Black Box Warning

📋 Counseling Dot Phrase

.QUETIAPINECOUNSEL
Discussed initiation/continuation of quetiapine [DOSE] mg PO [qHS/BID/TID] 
for [Schizophrenia/Bipolar/MDD augmentation/Insomnia-off label].

METABOLIC MONITORING: Weight, blood sugar, cholesterol will be checked 
regularly. Report significant weight gain between visits.

SEDATION: Strong sedation — do NOT drive until you know how it affects you. 
Take at bedtime for qHS dosing. Do not take extra doses.

DIZZINESS: Rise slowly from lying/sitting — low BP on standing possible.

OPHTHALMOLOGY: Eye exam recommended within 6 months of starting — can 
rarely affect lens clarity (cataracts).

MOVEMENT SIDE EFFECTS: Low risk but watch for tremors, restlessness, 
unusual movements — report these.

ELDERLY: Increased risk if you have dementia — discuss risk/benefit carefully.

Metabolic monitoring plan in place: [next labs ____].
AIMS exam [completed/scheduled].
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Aripiprazole (Abilify, Abilify Maintena LAI, Aristada LAI)

SGA / D2 Partial AgonistBlack Box

▼

Unique mechanism: D2 partial agonist (not full antagonist). Lowest metabolic risk of SGAs. Low prolactin effect. Most activating SGA. FDA indications: schizophrenia, bipolar I, MDD augmentation, autism irritability, Tourette's, agitation.

Severity	Side Effect	Notes
Common	Akathisia (inner restlessness)	Most common side effect — often mistaken for anxiety worsening; ask specifically
Common	Insomnia, activation	Most activating SGA — take AM; may worsen insomnia
Common	Nausea, headache	Early; usually resolves
Common	Mild weight gain	Less than most SGAs; lowest metabolic risk
Serious	Impulse control disorder	Gambling, hypersexuality, binge eating reported — dopaminergic partial agonism
Serious	TD, NMS	Class risks; lower TD risk than FGAs
Serious	Elderly dementia mortality	Black Box Warning

📋 Counseling Dot Phrase

.ARIPIPRAZOLECOUNSEL
Discussed initiation of aripiprazole [DOSE] mg PO daily for [Diagnosis].

ADVANTAGES: Lowest weight and metabolic risk of antipsychotics. Low prolactin 
elevation. Available as monthly injection (Maintena/Aristada) for adherence.

AKATHISIA — Most common side effect:
- Feeling of inner restlessness, urge to move, inability to sit still
- This is a medication side effect, NOT worsening anxiety or agitation
- Report immediately — dosing/medication adjustment available

IMPULSE CONTROL (rare): Tell me if you notice unusual urges around gambling, 
spending, eating, or sexual activity — rare but documented with this drug.

ACTIVATION: More stimulating than other antipsychotics — take in the morning 
if it causes insomnia.

Metabolic monitoring plan in place. AIMS exam [completed/scheduled].
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Risperidone (Risperdal, Risperdal Consta) / Olanzapine (Zyprexa)

SGABlack Box

▼

Feature	Risperidone	Olanzapine
Prolactin elevation	High — highest of SGAs	Moderate
Weight gain	Moderate	Very High — worst of SGAs
Metabolic syndrome	Moderate	Very High
EPS	Moderate (especially at >6 mg)	Low
Sedation	Moderate	High
LAI available	Yes (Consta 2-weekly, Perseris monthly)	Yes (Relprevv — REMS required)
Special concern	Gynecomastia, galactorrhea, amenorrhea from prolactin	Weight and diabetes risk — intensive lifestyle counseling required

Olanzapine Relprevv (LAI) — REMS Program: Post-injection delirium/sedation syndrome (PDSS) — patients must be observed for 3 hours post-injection at a registered healthcare facility. Certified prescribers and facilities only.

📋 Counseling Dot Phrase (Olanzapine)

.OLANZAPINECOUNSEL
Discussed initiation of olanzapine [DOSE] mg PO [daily/qHS] for [Diagnosis].

WEIGHT AND METABOLISM — HIGHEST RISK:
- Olanzapine causes significant weight gain — average 4–8+ kg over first year
- Increased risk of diabetes and high cholesterol
- Regular lab monitoring and weight checks are mandatory
- Proactive dietary and exercise counseling strongly recommended
- If weight gain is unacceptable, alternative medications available

SEDATION: Strong — take at bedtime. Do not drive until tolerability established.

Prolactin effects discussed for risperidone: [galactorrhea, sexual side effects, 
amenorrhea, bone density with long-term use].

Metabolic monitoring established. AIMS exam [completed/scheduled].
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Ziprasidone · Lurasidone · Cariprazine · Brexpiprazole

SGABlack Box

▼

Drug	Key Points	Must-Know Counseling
Ziprasidone (Geodon)	Highest QTc risk among SGAs; lowest metabolic risk; low weight gain	Take with 500+ calorie meal (doubles absorption). EKG required. Avoid with QT-prolonging drugs.
Lurasidone (Latuda)	FDA-approved for bipolar depression; low metabolic risk; moderate EPS; moderate prolactin	Take with 350+ calorie meal (3× better absorption). Good choice in metabolic-risk patients.
Cariprazine (Vraylar)	D3 > D2 partial agonist; FDA indications: schizophrenia, bipolar I, bipolar depression, MDD augmentation; long active metabolite (weeks)	Akathisia more common than aripiprazole. Very long half-life — side effects/drug interactions persist weeks after stopping.
Brexpiprazole (Rexulti)	D2 partial agonist like aripiprazole but less activating; FDA: schizophrenia, MDD augmentation, agitation in Alzheimer's	Better tolerated than aripiprazole in terms of akathisia. Weight gain moderate. Monitor per standard SGA protocol.

📋 Counseling Dot Phrase (Lurasidone — Food Requirement)

.LURASIDONECOUNSEL
Discussed initiation of lurasidone [40/80/120/160] mg PO daily for 
[Schizophrenia / Bipolar Depression].

FOOD REQUIREMENT — CRITICAL:
- Lurasidone MUST be taken with at least 350 calories of food
- Without food, only 1/3 of the medication is absorbed — it won't work
- If you forget to eat, wait until your next meal to take it

ADVANTAGES FOR THIS PATIENT:
- Lower weight and metabolic risk than many antipsychotics
- Effective for bipolar depression (few options in this class)

Standard SGA monitoring (metabolic, AIMS, EPS) in place.
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Antipsychotics — First Generation (FGAs / Typicals)

Haloperidol · Chlorpromazine · Fluphenazine · Perphenazine · Thiothixene

FGA Class Overview + Haloperidol / Fluphenazine / Chlorpromazine

FGABlack Box

▼

Class Risk Profile: Higher EPS, akathisia, and TD risk than SGAs. Narrow therapeutic window for some. Strong prolactin elevation universally. Significant anticholinergic burden (esp. low-potency). NMS risk.

Drug	Potency	EPS	Sedation	Anticholinergic	Orthostasis
Haloperidol (Haldol)	High	Very High	Low	Low	Low
Fluphenazine (Prolixin)	High	Very High	Low	Low	Low
Chlorpromazine (Thorazine)	Low	Low	Very High	High	High
Perphenazine (Trilafon)	Mid	Moderate	Moderate	Moderate	Moderate

⚠ FDA Black Box Warning — All Antipsychotics

Elderly patients with dementia-related psychosis treated with antipsychotics are at increased risk of death
Not approved for dementia-related psychosis

Neuroleptic Malignant Syndrome (NMS) — Emergency

NMS triad: Fever + rigidity + altered consciousness + autonomic instability. Higher risk with FGAs, rapid dose escalation, dehydration, high ambient temperature. Medical emergency — stop antipsychotic immediately, call 911, ICU-level care often needed. Bromocriptine and dantrolene used in management. Do not rechallenge with same agent.

LAI (Long-Acting Injectable) Counseling

Haloperidol Decanoate (monthly) / Fluphenazine Decanoate (biweekly or monthly): LAI formulations ensure consistent drug levels and eliminate daily pill adherence. Counsel: injection site reactions, cannot rapidly adjust dose after injection, slower onset of action changes. Overlap oral medication for first 3–4 weeks (haloperidol decanoate). Loading dose protocols vary by product — follow manufacturer guidance.

📋 Counseling Dot Phrase (Haloperidol)

.HALOPERIDOLCOUNSEL
Discussed initiation of haloperidol [DOSE] mg PO [daily/BID/TID] for [Diagnosis].
[OR: haloperidol decanoate [DOSE] mg IM every [4 weeks] for [Diagnosis].]

MOVEMENT SIDE EFFECTS (higher risk with this medication):
- Muscle stiffness, tremor, slowed movements (Parkinsonism) — report
- Restlessness, urge to move legs/pace (Akathisia) — report; treatable
- Involuntary movements of face, tongue, limbs (Tardive Dyskinesia) — 
  report any new movements; regular monitoring required
- Eye or neck muscle spasms (Dystonia) — go to ER if severe

EMERGENCY: If you develop high fever, severe muscle stiffness, confusion, 
rapid heartbeat — call 911 immediately (Neuroleptic Malignant Syndrome).

AIMS exam performed: [Score / Date].
Metabolic monitoring in place. Labs due: [date].
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Mood Stabilizers

Lithium · Valproic Acid · Carbamazepine · Lamotrigine · Oxcarbazepine

Lithium (Lithobid, Eskalith)

Mood Stabilizer

▼

Therapeutic window: 0.6–1.2 mEq/L (maintenance); 0.8–1.2 mEq/L (acute mania). Toxicity begins >1.5 mEq/L. Life-threatening at >2.0 mEq/L. Narrow therapeutic index — levels, renal function, and hydration critical.

Severity	Side Effect	Notes
Common	Polyuria, polydipsia	NDI (nephrogenic diabetes insipidus) — up to 40%; maintain hydration
Common	Tremor (fine)	Dose-related; β-blocker (propranolol) can treat; lower dose if problematic
Common	Weight gain	Average 4–7 kg; partially appetite-driven
Common	Cognitive blunting, memory	"Lithium fog" — dose or level adjustment may help
Common	GI (nausea, diarrhea)	Take with food; use ER formulation; diarrhea may be toxicity sign
Common	Acne, psoriasis exacerbation	Dermatologic; refer dermatology if needed
Common	Hypothyroidism	20–40% risk; monitor TSH q6 months; treat with levothyroxine if develops
Serious	Lithium toxicity	N/V/D, coarse tremor, confusion, ataxia, seizures, arrhythmia, death — level >1.5; EMERGENCY
Serious	Renal impairment (chronic)	Long-term lithium → CKD; monitor Cr/eGFR every 6 months
Serious	Ebstein's anomaly (pregnancy)	Relative cardiac teratogenicity — counsel; risk lower than historically reported but real
Serious	Cardiac conduction changes	T-wave changes; sinus node dysfunction at toxic levels
Rare	Hyperparathyroidism	Hypercalcemia; check Ca if symptomatic

⚠ Lithium Toxicity Warning

TOXICITY TRIGGERS: Dehydration (illness, heat, sweating, low fluid intake), NSAIDs (reduce renal clearance ~25%), ACE inhibitors/ARBs (↑ levels), thiazide diuretics (↑ levels), low-sodium diet. Toxicity signs: CALL/GO TO ER: coarse tremor, vomiting, diarrhea, slurred speech, confusion, unsteady gait, muscle twitching, seizures.

Baseline

BMP, Cr/eGFR, TSH, CBC, urinalysis, weight, EKG (if cardiac hx)

Level (initiation)

Check 5 days after each dose change; trough level (12h after last dose)

Level (stable)

Every 3–6 months; after any illness, dehydration, or new medication

Renal (BMP)

Every 6 months — lithium is nephrotoxic long-term

Thyroid (TSH)

Every 6 months — hypothyroidism in 20–40%

Calcium

Annual — hyperparathyroidism/hypercalcemia risk

Drug Interactions

NSAIDsReduce renal Li clearance ~25% — toxicity risk. Use acetaminophen instead.

ACE inhibitors / ARBsSignificantly increase lithium levels — monitor closely; may need dose reduction.

Thiazide diureticsIncrease lithium reabsorption → toxicity. Monitor levels closely or avoid.

SSRIs / SNRIsSerotonin syndrome risk (low); generally used together safely.

AntipsychoticsNeurotoxicity reported at high doses of both — monitor.

Pregnancy / Lactation

Pregnancy:Category D — Ebstein's anomaly risk (~0.1%). Risk lower than historical estimates. Fetal echo at 18–20 wk if exposed. Consider dose adjustment (increased clearance in pregnancy).

Lactation:AAP: Generally not recommended — high infant exposure, monitor infant levels if used

📋 Counseling Dot Phrase

.LITHIUMCOUNSEL
Discussed initiation/continuation of lithium [DOSE] mg PO [daily/BID/TID] 
for [Bipolar I / Bipolar II / Augmentation].

BLOOD LEVELS — CRITICAL:
- Lithium requires regular blood tests to ensure safe and effective levels
- Take dose the NIGHT BEFORE your lab, then go to lab BEFORE your morning dose
- (We need the "trough" level — 12 hours after last dose)
- Target level: [0.6–1.0 / 0.8–1.2] mEq/L
- Current level: [___] mEq/L — [within/above/below target]

TOXICITY WARNING — Know the Signs, Go to ER:
✦ Coarse hand tremor (different from fine tremor)
✦ Nausea, vomiting, diarrhea together
✦ Slurred speech, unsteady walking
✦ Confusion or unusual sleepiness
✦ Muscle twitching

WHAT RAISES YOUR LITHIUM LEVEL (DANGER):
- Dehydration: illness, vomiting, diarrhea, heavy sweating, not drinking
- NSAIDs: ibuprofen, naproxen, aspirin (regular dosing) — USE TYLENOL instead
- New blood pressure medications (ACE inhibitors, ARBs, diuretics) — always tell other providers you take lithium
- Low-salt diet

HYDRATION: Drink 2–3 liters of fluid daily. Maintain consistent salt intake.

KIDNEY + THYROID: Regular monitoring required. May develop low thyroid 
function over time — treatable with thyroid hormone.

PREGNANCY: Discuss with me before becoming pregnant — dose adjustment and 
extra monitoring needed. Use effective contraception unless planning pregnancy.

Patient verbalized understanding. Questions answered. Toxicity recognition instruction completed.
[Agreed to proceed / Declined].

Valproic Acid / Valproate (Depakote, Depakene, Depakote ER)

Mood Stabilizer / AEDBlack Box

▼

⚠ FDA Black Box Warnings (3 Separate)

Hepatotoxicity: Liver failure (sometimes fatal) — especially in children <2 years and with polytherapy. LFTs at baseline and q6 months. Stop if jaundice, abdominal pain, vomiting, or elevated LFTs.
Teratogenicity / Neural tube defects: 1–4% risk of neural tube defects (spina bifida). CONTRAINDICATED for migraine prophylaxis in pregnancy. Requires folate supplementation (4 mg/day). REMS program for women of childbearing potential — counseling and contraception documentation required.
Pancreatitis: Acute, sometimes fatal pancreatitis reported. Abdominal pain + nausea → check lipase; hold valproate.

Severity	Side Effect	Notes
Common	Weight gain	Average 4–8 kg; carnitine depletion, insulin resistance mechanism
Common	Hair loss (telogen effluvium)	Dose-dependent; zinc and selenium supplementation may help
Common	Tremor	Fine tremor; dose-related
Common	GI effects (nausea, vomiting)	Use ER formulation; take with food
Common	Sedation, cognitive blunting	Dose-dependent
Serious	Hepatotoxicity	Black Box — monitor LFTs; stop if symptomatic
Serious	Pancreatitis	Black Box — abdominal pain → lipase; hold drug
Serious	Neural tube defects	Black Box — avoid in pregnancy; REMS required
Serious	Thrombocytopenia, platelet dysfunction	Bleeding risk — check CBC/platelets; monitor
Serious	PCOS (polycystic ovary syndrome)	Hyperandrogenism, menstrual irregularity in women — screen; consider alternative
Rare	Hyperammonemia	Confusion without elevated LFTs — check ammonia; L-carnitine may help

Baseline

LFTs, CBC with platelets, BMP, pregnancy test (females), weight

Level

Therapeutic: 50–125 mcg/mL (general); 50–100 for bipolar maintenance; check trough

LFTs + CBC

Every 6 months; sooner if symptoms (jaundice, bruising, abdominal pain)

Females

REMS counseling; contraception confirmation; screen for PCOS annually

📋 Counseling Dot Phrase

.VALPROATECOUNSEL
Discussed initiation/continuation of valproate [DOSE] mg PO [daily/BID] 
for [Bipolar I mania / Seizure disorder / Migraine prophylaxis].

PREGNANCY WARNING (all females of childbearing potential):
- Valproate causes serious birth defects (spinal cord defects, neural tube defects)
- Risk is approximately 1–4% — significantly higher than other medications
- You MUST use effective contraception while taking this medication
- If you plan to become pregnant, discuss with me FIRST — we will change medications
- Take folic acid 4 mg daily as directed
- REMS program counseling documented [date]: [___]

LIVER MONITORING: Regular liver tests required. Call immediately if:
yellow skin/eyes, severe stomach pain, unusual nausea/vomiting

PANCREATITIS: Severe abdominal pain → stop medication and call ER.

WEIGHT AND HAIR LOSS: Common. Weight gain managed with diet. Hair thinning 
may occur — usually reversible; zinc/selenium supplements may help.

BLEEDING: Report unusual bruising or bleeding — platelet monitoring required.

Level [obtained/pending]: [___] mcg/mL (target 50–100 mcg/mL for bipolar).
Patient verbalized understanding of teratogenicity. REMS documentation completed.
Questions answered. [Agreed to proceed / Declined].

Carbamazepine (Tegretol, Equetro)

Mood Stabilizer / AEDBlack Box

▼

⚠ FDA Black Box Warnings

Aplastic anemia and agranulocytosis: Rare but potentially fatal. CBC baseline and periodic monitoring. Immediate CBC if fever, sore throat, infection.
Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN): Fatal skin reactions. Risk highest in first 4 months. HLA-B*1502 allele (Asian ancestry) dramatically increases SJS risk — MUST screen before prescribing in patients of Asian descent (Thai, Han Chinese, South Asian, Filipino).
Teratogenicity: Neural tube defects, fetal carbamazepine syndrome. Avoid in pregnancy if possible; use folate.

Autoinduction: Carbamazepine induces its own metabolism (CYP3A4 autoinducer) — levels drop 1–2 months after starting. Re-check levels at 4–6 weeks and after each dose change. Also induces metabolism of many other drugs.

Severity	Side Effect	Notes
Common	Dizziness, ataxia, diplopia	Dose-related; start low and titrate slowly
Common	Sedation, cognitive impairment	Common early; usually improves
Common	Nausea	Take with food; ER formulation preferred
Serious	SJS/TEN	Black Box — fever + rash → STOP immediately; ER evaluation
Serious	Aplastic anemia / agranulocytosis	Black Box — CBC at baseline and every 6–12 months; urgent if fever/infection
Serious	Hyponatremia (SIADH)	Common — check Na baseline and periodically, especially in elderly
Serious	Hepatotoxicity	Monitor LFTs; hepatitis, cholestasis reported
Serious	Drug interactions (CYP3A4 inducer)	Reduces levels of contraceptives, many other drugs dramatically

Key Drug Interactions (Strong CYP3A4 Inducer)

Oral contraceptivesReduces OCP efficacy — use barrier method or non-hormonal contraception.

WarfarinReduces INR — increased anticoagulation monitoring required.

MAOIsContraindicated — 14-day washout required.

ClozapineContraindicated — additive agranulocytosis risk.

Many antidepressantsReduces levels significantly (SSRIs, TCAs, bupropion) — higher doses may be needed.

📋 Counseling Dot Phrase

.CARBAMAZEPINECOUNSEL
Discussed initiation of carbamazepine [DOSE] mg PO [BID/TID] for [Bipolar / Trigeminal neuralgia].

HLA-B*1502 SCREENING (Asian ancestry patients):
- [Tested: negative/positive] — [Cleared to proceed / Contraindicated — alternative selected]
- This gene dramatically increases risk of severe skin reactions in some patients

SKIN REACTION — MEDICAL EMERGENCY:
- Rash + fever in first 4 months → STOP MEDICATION and go to ER immediately
- Do NOT wait — Stevens-Johnson Syndrome can be fatal
- Blistering, peeling, mucous membrane involvement = call 911

DRUG INTERACTIONS — THIS MEDICATION REDUCES LEVELS OF MANY OTHER DRUGS:
- Birth control pills may become LESS effective — use additional contraception
- Tell ALL prescribers you take carbamazepine before starting new medications

BLOOD LEVELS CHANGE OVER TIME: Level will be lower at 1–2 months 
due to autoinduction — follow-up level check required.

Labs obtained: CBC [___], LFTs [___], BMP [___], Level [___] (therapeutic 4–12 mcg/mL).
Patient verbalized understanding. SJS counseling documented.
Questions answered. [Agreed to proceed / Declined].

Lamotrigine (Lamictal)

Mood Stabilizer / AEDBlack Box

▼

Bipolar depression specialist: Best evidence for bipolar II depression maintenance. Excellent tolerability if titrated correctly. Weight-neutral. No metabolic effects. The ENTIRE challenge is the slow titration to avoid SJS.

⚠ FDA Black Box Warning — Serious Skin Reactions

Stevens-Johnson Syndrome (SJS): Slow titration protocol exists specifically to reduce this risk. Rash in first 2–8 weeks requires immediate evaluation. Benign rashes also occur — but all rashes must be evaluated. Discontinue immediately if rash is accompanied by fever, mucous membrane involvement, lymphadenopathy, blistering, or systemic symptoms.

Titration Protocol (SJS Prevention)

Week	Without Valproate	With Valproate (halves lamotrigine levels)
Weeks 1–2	25 mg/day	12.5 mg/day (or 25 mg every other day)
Weeks 3–4	50 mg/day	25 mg/day
Week 5	100 mg/day	50 mg/day
Week 6+	Target 200 mg/day	Target 100 mg/day

If patient misses ≥5 days of doses: Must restart at initial titration dose — do not jump back to current dose. Risk of SJS resets.

📋 Counseling Dot Phrase

.LAMOTRIGINECOUNSEL
Discussed initiation of lamotrigine per slow titration protocol for [Bipolar disorder / Seizures].

RASH PROTOCOL — THE MOST IMPORTANT THING:
- A serious, potentially fatal skin reaction (Stevens-Johnson Syndrome) 
  can occur — rare but real risk
- To prevent this, the dose is increased VERY slowly over weeks
- If you develop any rash while on lamotrigine — CALL ME BEFORE taking 
  next dose. Do NOT continue taking if you develop:
  ✦ Any rash (especially in first 2 months)
  ✦ Rash + fever, mouth sores, eye redness, blistering

MISSED DOSES — CRITICAL:
- If you miss 5 or more consecutive days, do NOT restart at current dose
- Call me — we must restart the slow titration from the beginning
- Set phone reminders for daily dosing

TITRATION SCHEDULE: [Provide patient with written schedule]

ADVANTAGES: Weight-neutral, no metabolic effects, few cognitive side effects.
Very well tolerated once at target dose.

DO NOT start valproate (Depakote) without telling me — it doubles lamotrigine levels 
and requires dose adjustment.

Patient verbalized understanding of rash protocol.
Written titration schedule provided. Questions answered.
[Agreed to proceed / Declined].

Oxcarbazepine (Trileptal)

AED / Mood

▼

Note: Structurally related to carbamazepine but fewer drug interactions (weaker CYP inducer). Used off-label for bipolar. Higher risk of hyponatremia than carbamazepine — most common reason for discontinuation. Still carries SJS/TEN risk but lower than CBZ. No HLA-B*1502 cross-reactivity data as strong as CBZ but caution still recommended in Asian patients.

Severity	Side Effect	Notes
Common	Hyponatremia	Most common reason for discontinuation; monitor Na at baseline, 4 wk, then q6 months
Common	Dizziness, ataxia, diplopia	Dose-related; less than CBZ
Serious	SJS/TEN	Rare — monitor for rash especially first 4 months
Serious	Hypersensitivity cross-reactivity with CBZ (~25%)	Ask about prior CBZ rash before prescribing OXC

📋 Counseling Dot Phrase

.OXCARBAZEPINECOUNSEL
Discussed initiation of oxcarbazepine [DOSE] mg PO [BID] for [Bipolar / Seizure].

SODIUM (SALT) MONITORING: This medication can lower your blood sodium.
Symptoms: headache, confusion, nausea, fatigue, seizures.
Blood sodium test required at [baseline / 4 weeks / 6 months].

RASH PROTOCOL: Same as carbamazepine — any rash + fever → stop and call.
Prior reaction to carbamazepine? [Yes/No — documented].

Drug interactions less than carbamazepine but still present with OCPs.
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Benzodiazepines

Alprazolam · Clonazepam · Lorazepam · Diazepam · Oxazepam · Temazepam

Benzodiazepine Class Overview

Schedule IVBlack BoxControlled

▼

⚠ FDA Black Box Warning (2020 — All Benzodiazepines)

Concurrent opioid use: Profound CNS depression, respiratory depression, death. Avoid concurrent use; if unavoidable, limit doses and duration, monitor closely.
Abuse, misuse, and addiction: Psychological and physical dependence possible.
Dependence and withdrawal: Life-threatening withdrawal (seizures, delirium) if abruptly discontinued after long-term use. Taper required.

Duration-of-Action Comparison

Drug	Half-life	Onset	Duration	Metabolites	Preferred In
Diazepam (Valium)	20–100h + active	Fast	Long	Active (desmethyl, oxazepam)	Alcohol withdrawal, muscle spasm
Chlordiazepoxide (Librium)	5–30h + active	Slow	Long	Active multiple	Alcohol withdrawal (preferred)
Clonazepam (Klonopin)	20–50h	Intermediate	Long	Inactive	Panic disorder, seizures, long-term anxiety
Alprazolam (Xanax)	11–15h	Fast	Short-intermediate	Inactive	Panic disorder (short-term); highest abuse potential
Lorazepam (Ativan)	10–20h	Intermediate	Intermediate	Inactive	Acute anxiety, procedural, elderly (no active metabolites)
Oxazepam (Serax)	5–20h	Slow	Short	None	Elderly, hepatic disease — gold standard in liver disease
Temazepam (Restoril)	8–22h	Intermediate	Short-intermediate	None	Sleep onset/maintenance

Benzodiazepine Tapering Protocol Principles

Tapering guidelines: Reduce by no more than 5–10% every 2–4 weeks (or slower for long-term users). Convert short-acting to long-acting (diazepam) for smoother taper. Ashton Manual principles: gradual, patient-paced, supportive care. Estimate total taper time: 6–18 months for long-term users. Withdrawal symptoms: anxiety, insomnia, tremor, sweating, seizures. Seizure risk: greatest when stopping high-dose, long-duration benzodiazepines abruptly.

Severity	Side Effect	Notes
Common	Sedation, drowsiness	Impairs driving — do not drive until tolerability established
Common	Cognitive impairment, anterograde amnesia	Memory encoding impaired; cumulative with chronic use
Common	Tolerance (efficacy decreases)	Develops over weeks–months; dose escalation not recommended
Common	Emotional blunting, depression	Long-term use associated with depression and emotional numbing
Serious	Dependence and withdrawal	Physical dependence within weeks; life-threatening withdrawal — Black Box Warning
Serious	Respiratory depression	With opioids, alcohol, sleep apnea — Black Box Warning
Serious	Fall risk / fractures	Elderly — Beers Criteria; significantly increases fall and hip fracture risk
Serious	Disinhibition / paradoxical agitation	In elderly, TBI, dementia — may worsen aggression
Serious	Seizures on abrupt discontinuation	Life-threatening — NEVER stop abruptly

📋 Counseling Dot Phrase (New Prescription)

.BENZODIAZEPINECOUNSEL
Discussed initiation of [alprazolam/clonazepam/lorazepam] [DOSE] mg PO 
[PRN/BID/TID] for [Panic disorder / GAD / Acute anxiety].

CONTROLLED SUBSTANCE — Schedule IV. PDMP checked: [date] — [findings].
Controlled substance agreement [signed / on file].

IMPORTANT SAFETY RULES:
1. OPIOIDS: NEVER combine with opioid pain medications, heroin, or opioid 
   cough suppressants — combination causes fatal respiratory depression
2. ALCOHOL: Do not drink alcohol while taking this medication — severe 
   sedation and breathing problems
3. DRIVING: Do not drive until you know how this affects you
4. DO NOT STOP ABRUPTLY: Physical dependence develops with regular use. 
   Stopping suddenly can cause seizures — always taper under guidance
5. TOLERANCE: This medication becomes less effective over time — 
   dose increase is NOT appropriate; discuss alternatives

DEPENDENCE RISK DISCLOSED: Physical and psychological dependence possible.
Goal is short-term use / PRN use for acute anxiety only.

FALLS (elderly patients): This medication significantly increases fall risk.
Use extra caution: grip rails, avoid nighttime walking alone, no ladders.

For [clonazepam — long-acting]: Preferred over alprazolam for lower abuse potential.
For [alprazolam — short-acting]: Highest abuse potential in class; monitor closely.

UDS [obtained/required per policy]. 
Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Stimulants (ADHD Treatment)

Methylphenidate · Amphetamine Salts · Lisdexamfetamine · Dextroamphetamine

Stimulant Class Overview

Schedule IIBlack BoxControlled

▼

⚠ FDA Black Box Warning — All Schedule II Stimulants

High potential for abuse and dependence: Assess risk of abuse prior to prescribing. Misuse may cause sudden death and serious cardiovascular adverse events.
Schedule II controlled substance — highest restriction level for prescribing. State PDMP check required before each prescription in most states.

Drug	Class	Duration	Onset	Abuse Potential	Notes
Methylphenidate IR (Ritalin)	MPH	4–6h	30–45 min	Moderate	Frequent dosing; school dosing challenges
Methylphenidate ER (Concerta)	MPH	10–12h	1–2h	Moderate	Cannot crush; OROS delivery
Methylphenidate patch (Daytrana)	MPH	Variable	2h	Moderate	Apply 2h before needed; remove after 9h
Mixed amphetamine salts IR (Adderall)	AMP	4–6h	30–60 min	High	Most commonly diverted stimulant
Mixed amphetamine salts XR (Adderall XR)	AMP	10–12h	1h	High	Can open capsule; sprinkle on food
Lisdexamfetamine (Vyvanse)	AMP prodrug	12–14h	1–2h	Lower (prodrug)	Must be enzymatically converted — snorting/injecting less effective
Dextroamphetamine (Dexedrine)	d-AMP	4–6h / 8h	30 min	High	Pure dextroamphetamine isomer

Severity	Side Effect	Notes
Common	Decreased appetite, weight loss	Morning dose suppresses lunch appetite; consider drug holiday on weekends
Common	Insomnia	Avoid dosing after 3 PM; use immediate-release for flexibility
Common	Elevated BP and HR	Monitor at every visit; cardiovascular screening before initiation
Common	Headache, dry mouth	Common early; typically resolves
Common	Irritability, emotional lability (rebound)	As medication wears off; overlap with next dose or switch to long-acting
Serious	Cardiovascular events (sudden death)	Rare; screen for cardiac history/symptoms before prescribing; EKG if indicated
Serious	Growth suppression (children)	Monitor height/weight at every visit; drug holidays may preserve growth
Serious	Tic exacerbation	May precipitate or worsen tics in susceptible individuals; monitor closely
Serious	Mania/psychosis precipitation	Screen for bipolar before prescribing; can unmask psychosis
Serious	Abuse, misuse, diversion	Schedule II — highest controlled substance level. Structured monitoring.
Rare	Peripheral vasospasm (Raynaud's)	Tingling, color changes in fingers — dose adjustment
Rare	Priapism (rare)	Painful erection >4h — ER

Cardiovascular Screening Protocol

Pre-stimulant cardiac screen: Family history of sudden cardiac death (<35yo), personal history of arrhythmia, structural heart disease, hypertrophic cardiomyopathy, Long QT. Symptoms: palpitations, syncope, exertional chest pain, dyspnea. EKG indicated if: known cardiac condition, abnormal cardiac exam, history of syncope, family history SCD. Blood pressure and heart rate at every visit (monthly × 3, then every 6 months).

Drug Holiday Counseling

Planned drug holidays: Weekends, summers (children) — allows appetite recovery, growth, assessment of baseline ADHD symptoms. Not appropriate for all patients (adults who drive, high-risk safety situations). Discuss with patient/family. Document decision and rationale.

📋 Counseling Dot Phrase

.STIMULANTCOUNSEL
Discussed initiation of [methylphenidate/amphetamine salts/lisdexamfetamine] 
[DOSE] mg PO [daily/BID] for [ADHD — combined/inattentive/hyperactive type].

SCHEDULE II CONTROLLED SUBSTANCE:
- PDMP checked: [date] — [no concerns / findings]
- Prescription cannot be called in by phone; new written Rx required each month
- [State-specific policies reviewed]

CONTROLLED SUBSTANCE AGREEMENT signed: [Yes / Date]
Diversion risk discussed: medication for personal use only; 
safe storage required (locked); do not share or sell.

CARDIOVASCULAR MONITORING:
- BP and heart rate checked today: [BP ___] [HR ___]
- Monitor at each visit — will track trend
- Report: chest pain, palpitations, racing heart, fainting
- Cardiac history/family history reviewed: [___]
- EKG [obtained / not indicated at this time]

APPETITE AND WEIGHT (children):
- Appetite suppressed during medication hours — eat a good breakfast BEFORE medication
- Height and weight tracked at every visit — growth monitoring
- Drug holiday [discussed/planned]: [weekends/summer]

INSOMNIA: Take all doses before [12 PM / 3 PM]. Report sleep difficulties.

TIC MONITORING: Report any new repetitive movements, sounds, or motor habits.

ABUSE RISK: Medication is Schedule II with high abuse potential. 
UDS policy: [obtained today / as per controlled substance agreement].

Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Non-Stimulant ADHD Medications

Atomoxetine · Guanfacine · Clonidine · Viloxazine

Non-Stimulant ADHD Class Overview

Non-ScheduledBlack Box

▼

Advantages over stimulants: No abuse potential, no Schedule II restriction, no PDMP required, can be useful in patients with comorbid anxiety, tic disorders, substance use disorders, or where stimulants are contraindicated or failed.

Drug	Mechanism	Onset of Effect	Key SE	Notes
Atomoxetine (Strattera)	Selective NE reuptake inhibitor	4–8 weeks (slow)	Suicidality BBW, hepatotoxicity, sexual SE, activation	First non-stimulant approved for ADHD; good for comorbid anxiety
Viloxazine ER (Qelbree)	Selective NE reuptake inhibitor (newer)	4–8 weeks	Suicidality BBW, somnolence, decreased appetite, irritability	CYP1A2 inhibitor — raises caffeine, theophylline levels
Guanfacine ER (Intuniv)	α2A agonist	2–4 weeks	Sedation, hypotension, bradycardia, rebound hypertension on abrupt stop	Adjunct or monotherapy; approved children 6–17yo; used off-label adults
Clonidine ER (Kapvay)	α2 agonist (non-selective)	2–4 weeks	More sedation than guanfacine, hypotension, rebound hypertension	Also used for tics (Tourette's), PTSD nightmares; BID dosing required

⚠ FDA Black Box Warning — Atomoxetine + Viloxazine

Suicidal ideation in children and adolescents: Increased risk of suicidal thinking in children/teens. Monitor closely. Instruct patient/family to report unusual mood changes, worsening depression, or suicidal thoughts — especially during first few months and after dose changes. Also: Atomoxetine hepatotoxicity — rare but serious liver failure reported. Discontinue if jaundice or elevated LFTs.

📋 Counseling Dot Phrase (Atomoxetine)

.ATOMOXETINECOUNSEL
Discussed initiation of atomoxetine [DOSE] mg PO [daily/BID] for [ADHD].

NON-STIMULANT ADVANTAGE: Not a controlled substance — no abuse potential.

SLOW ONSET: Full benefit takes 4–8 weeks — do not judge effectiveness too early.

SUICIDALITY WARNING (children/teens):
- May increase suicidal thoughts in young people initially
- Parents/guardians: watch for mood changes, increased sadness, unusual behavior
- Call immediately if suicidal thoughts develop

LIVER: Rare risk of liver damage. Report: yellow skin/eyes, dark urine, 
abdominal pain, unexplained fatigue.

SEXUAL SIDE EFFECTS: Similar to SSRIs — decreased libido, delayed orgasm 
in adults. Report if problematic.

BLOOD PRESSURE/HEART RATE: Slight elevation possible — monitored at visits.

CYP2D6 POOR METABOLIZERS: If you have difficulty metabolizing certain 
medications, levels may be higher — dose adjustment may be needed.

Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

📋 Counseling Dot Phrase (Guanfacine/Clonidine)

.ALPHAGONISTCOUNSEL
Discussed initiation of [guanfacine/clonidine] [DOSE] mg PO [daily/BID] for [ADHD / Tics / PTSD nightmares].

SEDATION: Can be significant early on — avoid driving until tolerability established.
Typically improves after 1–2 weeks as body adjusts.

LOW BLOOD PRESSURE: Rise slowly from sitting/lying — may feel dizzy, lightheaded.
Report fainting or extreme dizziness.

DO NOT STOP ABRUPTLY: Rebound high blood pressure can occur with sudden 
discontinuation — always taper slowly under guidance.

CLONIDINE specifically: Twice-daily dosing required. More sedating than guanfacine.

BP and HR checked today: [BP ___] [HR ___]. Will monitor at each visit.

Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Substance Use Disorder (SUD) Medications

Buprenorphine · Naltrexone · Acamprosate · Disulfiram · Varenicline

Buprenorphine / Buprenorphine-Naloxone (Subutex, Suboxone, Sublocade)

MOUD / Schedule IIIBlack BoxREMS

▼

⚠ FDA Black Box Warning

Respiratory depression and death: Especially with concurrent benzodiazepines, opioids, alcohol, or other CNS depressants. Risk highest in opioid-naive patients.
Neonatal opioid withdrawal syndrome (NOWS): Prolonged neonatal withdrawal if used during pregnancy. Neonatology consultation required for delivery planning.
Risk of diversion and misuse — combination with naloxone (Suboxone) designed to reduce IV diversion.

Precipitated withdrawal risk: Buprenorphine is a partial agonist with high receptor affinity. Starting too early after opioid use displaces full agonists — causes abrupt, severe withdrawal. Clinical Opiate Withdrawal Scale (COWS) ≥8–12 required before induction. Standard induction: COWS ≥8–12 and minimum 12–24h since last short-acting opioid (longer for methadone or long-acting opioids).

Severity	Side Effect	Notes
Common	Constipation	Opioid effect; bowel regimen typically needed
Common	Nausea, headache	Early induction side effects; usually resolve
Common	Sweating, insomnia	Particularly early in treatment; adjust dose timing
Common	Sublingual: dental erosion	Rinse mouth after sublingual films; oral hygiene important
Serious	Respiratory depression	With CNS depressants — Black Box Warning
Serious	Precipitated withdrawal	If started too early — severe, self-limiting; supportive care
Serious	Liver enzyme elevation	Hepatitis B/C common in this population — baseline LFTs; monitor
Rare	QTc prolongation (high-dose)	At very high doses; standard doses generally safe

Baseline

LFTs, hepatitis B/C, HIV, urine drug screen, PDMP, COWS score

Monthly (stable)

UDS, PDMP check, prescription, assess diversion risk

LFTs

Every 3–6 months; more frequently if hepatic disease

Dose assessment

At each visit — cravings, withdrawal symptoms, diversion, adherence

📋 Counseling Dot Phrase

.BUPRENORPHINECOUNSEL
Discussed initiation of buprenorphine/naloxone [DOSE] mg SL [daily/BID/TID] 
for Opioid Use Disorder (OUD).

INDUCTION PROTOCOL REVIEWED:
- Do NOT take first dose until you are in moderate withdrawal (COWS ≥8)
- Wait [12–24h] after last short-acting opioid use
- If you take too early: PRECIPITATED WITHDRAWAL — sudden, severe withdrawal
- COWS score assessed today: [___]

CRITICAL SAFETY RULES:
- NEVER combine with benzodiazepines, alcohol, or other opioids without 
  medical guidance — fatal respiratory depression risk
- Narcan (naloxone) prescribed and reviewed
- Store medication locked — keep away from children and others
- Do not share — this medication is for your use only

DENTAL HEALTH: Rinse mouth with water after each sublingual dose; 
brush teeth 30 minutes after. Film formulation causes dental erosion.

PREGNANCY: Continue treatment during pregnancy — stopping is more dangerous 
than continuing. NOWS monitoring at delivery. Neonatology team involved.

DIVERSION: This is a controlled substance monitored via state PDMP.
UDS required per treatment agreement.

PDMP checked: [date] — [findings].
Controlled substance agreement [signed / on file / reviewed].

Patient verbalized understanding of induction protocol and safety rules.
Questions answered. [Agreed to proceed].

Naltrexone (Vivitrol IM monthly, ReVia PO daily)

Opioid Antagonist / AUD MOUDBlack Box

▼

⚠ FDA Black Box Warning

Hepatotoxicity: Naltrexone can cause hepatocellular injury at excessive doses. Monitor LFTs. Discontinue if signs of hepatitis develop. Note: Risk primarily at doses above recommended range; standard OUD/AUD doses have good safety record with LFT monitoring.

Must be opioid-free ≥7–10 days before starting (7 days for short-acting opioids; 10–14 days for methadone or long-acting opioids). Starting in opioid-dependent patients causes precipitated withdrawal. Verify with UDS before injection.

Severity	Side Effect	Notes
Common	Nausea (oral form)	Take with food; common in first weeks
Common	Injection site reactions (Vivitrol)	Pain, redness, bruising, induration — report severe nodules
Common	Headache, fatigue	Typically resolves
Common	Dysphoria, anhedonia	Opioid system blockade — reduced pleasure from food, activities; usually transient
Serious	Hepatotoxicity	Black Box — LFTs at baseline and periodically
Serious	Overdose risk after naltrexone	Opioid tolerance is lost — if patient relapses after blockade wears off, overdose risk is very HIGH
Serious	Opioid pain management blocked	Cannot use opioid pain medications; regional anesthesia preferred; alert surgical team

📋 Counseling Dot Phrase

.NALTREXONECOUNSEL
Discussed initiation of naltrexone [50 mg PO daily / 380 mg IM monthly] 
for [Opioid Use Disorder / Alcohol Use Disorder].

OPIOID-FREE REQUIREMENT:
- You must be completely opioid-free for [7–10 days] before this medication
- If taken too early: severe, immediate withdrawal
- UDS obtained today: [results] — [cleared to proceed / not yet ready]

TOLERANCE LOSS WARNING (OUD patients):
- While on naltrexone, your opioid tolerance is reduced or eliminated
- If you stop naltrexone and use opioids at old doses — HIGH RISK OF OVERDOSE
- Carry Narcan. Friends and family should have Narcan.
- This is a life-or-death safety issue

OPIOID PAIN MEDICATIONS: While on naltrexone, opioid pain medications 
will NOT work. Before any surgery, dental work, or procedure — tell your 
providers you are on naltrexone. Regional anesthesia alternatives available.

ALCOHOL USE DISORDER: Naltrexone reduces cravings and rewarding effects 
of alcohol. Works best when taken before drinking situations (oral form) 
or consistently (Vivitrol). Does not make you sick from alcohol.

LIVER MONITORING: Labs checked [baseline/today]: [___].
Next LFT check: [date].

Patient verbalized understanding of overdose risk and opioid-free requirement.
Questions answered. [Agreed to proceed / Declined].

Acamprosate · Disulfiram · Varenicline

AUD / SmokingBlack Box

▼

Drug	Indication	Key Side Effects	Critical Counseling
Acamprosate (Campral)	AUD — maintaining abstinence	Diarrhea, nausea; no hepatic metabolism — safe in liver disease	Requires abstinence before starting; no effect on cravings-to-drink but reduces PAWS symptoms; TID dosing is adherence challenge
Disulfiram (Antabuse)	AUD — aversion therapy	Disulfiram-ethanol reaction (flushing, nausea, vomiting, hypotension, palpitations, dyspnea — potentially fatal); hepatotoxicity; peripheral neuropathy	NEVER give to someone who has had alcohol in last 12h or who is not fully aware of reaction. Counsel on hidden alcohol in foods, cough syrups, aftershave, vinegar. Carries hepatotoxicity risk — monitor LFTs.
Varenicline (Chantix)	Smoking cessation	Nausea (most common), insomnia, vivid dreams, headache	Black Box Warning: neuropsychiatric adverse events (depression, suicidal ideation, mood changes) — removed from label 2016 after re-analysis but still monitor. Take with food and full glass of water. Start 1 week before quit date.

📋 Counseling Dot Phrase (Disulfiram)

.DISULFIRAMCOUNSEL
Discussed initiation of disulfiram [250/500] mg PO daily for Alcohol Use Disorder.

DISULFIRAM-ALCOHOL REACTION — CRITICAL SAFETY:
- If you drink ANY alcohol while taking this medication, you will have 
  a severe, dangerous reaction within minutes: flushing, severe nausea, 
  vomiting, racing heart, difficulty breathing, very low blood pressure
- This reaction can be LIFE-THREATENING — it is not safe
- This includes hidden alcohol: vanilla extract, some cough syrups, 
  mouthwash, some sauces, wine-based foods, hand sanitizer (absorbed)

DO NOT TAKE if you have had any alcohol in the last 12 hours.
Must be fully abstinent before starting.

LIVER MONITORING: LFTs baseline and every 3–6 months.

This medication works as a deterrent — it does not reduce cravings.
Maximum effectiveness when patient is MOTIVATED for abstinence.

Patient verbalized understanding of alcohol reaction. Abstinent status confirmed.
Questions answered. [Agreed to proceed / Declined].

Sleep Agents

Zolpidem · Eszopiclone · Suvorexant · Lemborexant · Ramelteon · Doxepin (low-dose)

Sleep Agent Class Overview

Various ClassesBlack BoxSome Controlled

▼

⚠ FDA Black Box Warning — Z-Drugs (Zolpidem, Eszopiclone, Zaleplon) — 2019

Complex sleep behaviors: Sleepwalking, sleep-driving, making phone calls, preparing/eating food while not fully awake — sometimes resulting in serious injury or death. Reported even at first dose, at recommended doses, and without prior complex sleep behavior. Discontinue if patient reports any unusual sleep behavior. Contraindicated in patients with prior complex sleep behavior on any sedative-hypnotic.

Drug	Class / Schedule	Sleep Type	Duration	Abuse Risk	Key Note
Zolpidem (Ambien, Ambien CR)	Z-drug / Sched IV	Onset	Short (IR) / Intermediate (CR)	Moderate	Female dose = 5 mg (next-day impairment); max 10 mg males. Strong parasomnias risk.
Eszopiclone (Lunesta)	Z-drug / Sched IV	Onset + maintenance	Intermediate	Moderate	Metallic/bitter taste common. Longer acting — more next-morning sedation.
Suvorexant (Belsomra)	Orexin antagonist / Sched IV	Onset + maintenance	Intermediate	Low	Novel mechanism — no muscle relaxation/respiratory effects. Next-day impairment possible. Avoid with strong CYP3A4 inhibitors.
Lemborexant (Dayvigo)	Orexin antagonist / Sched IV	Onset + maintenance	Intermediate	Low	Preferred in elderly — less next-morning impairment than suvorexant. No respiratory depression.
Ramelteon (Rozerem)	MT1/MT2 agonist / Non-scheduled	Onset	Short	None	No abuse potential. Works best for circadian sleep issues. Very mild effect — sets expectations. Safe in respiratory disease.
Doxepin 3–6 mg (Silenor)	H1 antagonist / Non-scheduled	Maintenance	Intermediate	None	Specifically approved for sleep maintenance insomnia. Avoid within 3h of high-fat meal. No dependence.

📋 Counseling Dot Phrase (Zolpidem)

.ZOLPIDEMCOUNSEL
Discussed initiation of zolpidem [5/10] mg PO qHS PRN for Insomnia.

DOSE: [5 mg for females] [5–10 mg for males] — lower dose reduces next-day impairment.

COMPLEX SLEEP BEHAVIORS — SERIOUS RISK:
- Sleepwalking, sleep-driving, eating, making calls while not awake
- Can occur even at first dose, at recommended dose
- If this happens — STOP medication and call immediately
- Tell family members to watch for unusual nighttime behavior

NEXT-MORNING IMPAIRMENT:
- Do NOT drive or operate machinery the morning after taking this medication
- Impairment may persist beyond 8 hours, especially in women, elderly, 
  and those who take higher doses
- Take ONLY when you have at least 7–8 hours for sleep

ALCOHOL: Never combine — additive CNS depression, dangerous.
CONTROLLED SUBSTANCE: Dependence possible with regular use.
Intended for short-term use or PRN — not nightly long-term use if avoidable.

Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Anxiolytics & Other

Buspirone · Hydroxyzine · Gabapentin · Pregabalin · Propranolol · Prazosin

Non-Benzodiazepine Anxiolytics Class Overview

Non-Scheduled / Various

▼

Drug	Mechanism	Primary Use	Key SE	Counseling Points
Buspirone (Buspar)	5-HT1A partial agonist	GAD (not panic)	Dizziness, nausea, headache; no sedation, no dependence	Takes 2–4 weeks to work. No PRN use — must be taken daily. No abuse potential — good alternative to benzos.
Hydroxyzine (Vistaril, Atarax)	H1 antihistamine	PRN anxiety, sleep, pruritus	Sedation, dry mouth, anticholinergic; QTc at high doses	Immediate effect (PRN usable). No dependence. Sedation is dose-dependent. Use with caution in elderly (Beers Criteria — anticholinergic).
Gabapentin (Neurontin)	α2δ voltage-gated Ca channel	Off-label anxiety, PTSD, SUD, neuropathic pain	Sedation, dizziness, ataxia, weight gain, edema; low abuse potential but misuse documented	Not FDA-approved for anxiety/psychiatric use. Some states monitoring or scheduling. Avoid abrupt discontinuation in high-dose users.
Pregabalin (Lyrica)	α2δ voltage-gated Ca channel	GAD (off-label), neuropathic pain, fibromyalgia	Sedation, dizziness, weight gain, peripheral edema; Schedule V	FDA-approved for epilepsy, neuropathic pain, fibromyalgia; GAD use off-label in US. Schedule V — abuse monitoring warranted.
Propranolol (Inderal)	Non-selective β-blocker	Performance anxiety (off-label)	Bradycardia, hypotension, fatigue, bronchospasm (avoid in asthma)	PRN for situational anxiety only. Not effective for generalized anxiety. Check HR/BP before each use. Contraindicated: asthma, severe bradycardia, decompensated HF.
Prazosin (Minipress)	α1 adrenergic blocker	PTSD nightmares (off-label)	Orthostatic hypotension (first-dose effect), dizziness, headache, syncope	Start at bedtime with low dose (1 mg) — first-dose syncope risk. Titrate slowly. Excellent evidence for PTSD nightmare reduction. Not a DEA controlled substance.

📋 Counseling Dot Phrase (Buspirone)

.BUSPIRONECOUNSEL
Discussed initiation of buspirone [5/10/15] mg PO [BID/TID] for GAD.

NON-BENZODIAZEPINE ADVANTAGE:
- No addiction potential. No physical dependence. No withdrawal.
- Does not cause sedation or impair driving.
- Safe for long-term use.

IMPORTANT — DOES NOT WORK PRN:
- Buspirone must be taken EVERY day on a schedule to work
- It is NOT a PRN medication — skip doses and it won't be effective
- Full anxiety relief takes 2–4 weeks — do not judge too early

DOES NOT WORK WELL IF: You are currently taking benzodiazepines regularly
(buspirone less effective when used alongside benzos).

Side effects: mild dizziness, headache, nausea early on — usually resolve.
No sexual side effects (unlike SSRIs).

Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

📋 Counseling Dot Phrase (Prazosin for PTSD Nightmares)

.PRAZOSINCOUNSEL
Discussed initiation of prazosin [1] mg PO qHS for PTSD-related nightmares.

OFF-LABEL USE: Prazosin is a blood pressure medication used off-label 
to reduce trauma nightmares. Not FDA-approved for PTSD but has strong evidence.

FIRST-DOSE SYNCOPE:
- First dose can cause significant dizziness and fainting — especially 
  when getting up from bed
- Take the first dose lying down at bedtime
- Rise slowly; sit on edge of bed before standing
- Do not get up suddenly during the night

TITRATION: Starting at lowest dose; will increase gradually to find 
effective dose for nightmares. Blood pressure monitored.

BLOOD PRESSURE MONITORING: BP [today: ___]. 
If you develop persistent lightheadedness, dizziness, or fainting — call.

Current BP medications reviewed — additive hypotension risk considered.

Patient verbalized understanding. Questions answered. [Agreed to proceed / Declined].

Psychotropic Side Effects Library

Quick Navigation

Selective Serotonin Reuptake Inhibitors (SSRIs)

Sertraline (Zoloft)

Escitalopram (Lexapro)

Fluoxetine (Prozac, Sarafem)

Paroxetine (Paxil, Paxil CR)

Citalopram (Celexa)

Fluvoxamine (Luvox, Luvox CR)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Venlafaxine (Effexor, Effexor XR)

Duloxetine (Cymbalta)

Desvenlafaxine (Pristiq) / Levomilnacipran (Fetzima)

Atypical Antidepressants

Bupropion (Wellbutrin SR/XL, Zyban)

Mirtazapine (Remeron)

Trazodone (Desyrel, Oleptro)

Vilazodone (Viibryd) / Vortioxetine (Trintellix)

Tricyclic Antidepressants (TCAs)

Tricyclic Antidepressants — Class Overview

Antipsychotics — Second Generation (SGAs)

SGA Class Overview — Metabolic & Safety Comparison

Quetiapine (Seroquel, Seroquel XR)

Aripiprazole (Abilify, Abilify Maintena LAI, Aristada LAI)

Risperidone (Risperdal, Risperdal Consta) / Olanzapine (Zyprexa)

Ziprasidone · Lurasidone · Cariprazine · Brexpiprazole

Antipsychotics — First Generation (FGAs / Typicals)

FGA Class Overview + Haloperidol / Fluphenazine / Chlorpromazine

Mood Stabilizers

Lithium (Lithobid, Eskalith)

Valproic Acid / Valproate (Depakote, Depakene, Depakote ER)

Carbamazepine (Tegretol, Equetro)

Lamotrigine (Lamictal)

Oxcarbazepine (Trileptal)

Benzodiazepines

Benzodiazepine Class Overview

Stimulants (ADHD Treatment)

Stimulant Class Overview

Non-Stimulant ADHD Medications

Non-Stimulant ADHD Class Overview

Substance Use Disorder (SUD) Medications

Buprenorphine / Buprenorphine-Naloxone (Subutex, Suboxone, Sublocade)

Naltrexone (Vivitrol IM monthly, ReVia PO daily)

Acamprosate · Disulfiram · Varenicline

Sleep Agents

Sleep Agent Class Overview

Anxiolytics & Other

Non-Benzodiazepine Anxiolytics Class Overview