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Escitalopram in Pregnancy/Breastfeeding
A 36-year-old woman with obsessive-compulsive disorder had been successfully treated for 1 year with 30 mg/day escitalopram (Lexapro) when she stopped the medication. The following month she became pregnant and for the first 6 months her clinical course was uneventful. She then experienced a major depressive episode for which 20 mg/day escitalopram was started. The pregnancy proceeded normally, with no apparent fetal anomalies and the patient remained psychiatrically stable. However, because its parent drug citalopram has been associated with adverse neonatal outcomes, escitalopram was tapered and discontinued during the final month of pregnancy. A healthy infant was born and the mother chose to breastfeed. Depressive symptoms recurred 15 days after delivery and 20 mg/day escitalopram was restarted. Breastfeeding was continued, and at 3 months there appeared to be no adverse effects in the infant.
Gentile S: Escitalopram late in pregnancy and while breast-feeding. Annals of Pharmacotherapy 2006;40 (September):1696–1697.From Salerno, Italy.
Drug Trade Names: citalopram—Celexa; escitalopram—Lexapro
From Psychiatry Drug Alerts November 2006
Infant exposure to escitalopram and its main metabolite demethylescitalopram appeared to be low and not associated with developmental delays in a study of 8 mother–infant pairs.1
All mothers were breastfeeding while undergoing escitalopram treatment for postpartum depression between 1 and 10 months after delivery. The average escitalopram dose was 10 mg/day and the average treatment duration was 55 days. Blood samples were obtained at regular intervals over 24 hours and women collected samples of breast milk before the morning dose and before and after each infant feeding. Infants were examined clinically and mothers were asked about the baby’s well-being.
The total dose of escitalopram plus demethylescitalopram in breast milk was about 5% of the maternal weight-adjusted dose. Absolute escitalopram doses in the infants were about 50% lower than those of citalopram in an earlier study.2 Clinical assessment of the infants found no adverse drug effects or developmental delays. Plasma was obtained for escitalopram assay in 5 infants; 4 had levels below the limit of detection, and levels were detectable but low in the fifth.
The authors conclude that escitalopram is safe for use during pregnancy, but warn against basing a conclusion on a sample this small.
1Rampono J, Hackett L, Kristensen J, Kohan R, et al: Transfer of escitalopram and its metabolite demethylescitalopram into breast milk. British Journal of Clinical Pharmacology 2006;62 (September):316–322. From the Women's and Children’s Health Service, Subiaco, Australia; and other institutions. Funded by Lundbeck Australia Pty. Ltd.
2Schmidt K, et al: Citalopram and breast-feeding: serum concentration and side effects in the infant. Biological Psychiatry 2000;47:164–165.
Drug Trade Names: citalopram—Celexa; escitalopram—Lexapro
From Psychiatry Drug Alerts November 2006
Risperidone Concentrations in Breast Milk
Maternal
risperidone (Risperdal) use during breastfeeding does not appear to pose
a threat to healthy full-term infants.1
Concentrations
of risperidone and its metabolite were measured in the breast milk of 3 women
receiving risperidone treatment and in serum samples from 2 infants aged 6
weeks and 3 months (1 patient was experiencing treatment-related galactorrhea
and had not given birth). Patients were receiving risperidone dosages of 1.5–4
mg/day and infant dosages (absolute and relative to maternal dosage) from
breast milk were calculated. Neither risperidone nor its metabolite was
detectable in the infant plasma samples and the absolute and relative
risperidone dosages were 0.32 mcg/kg/day and 2.8 % of the maternal dose,
respectively for 1 infant and 0.06 mcg/kg/day and 4.7%, respectively for the
other infant. Both infants were thriving and reaching developmental milestones
with no adverse effects of maternal risperidone treatment noted. Estimated
absolute and relative infant dosages were 0.88 mcg/kg/day and 2.3% in the
patient with galactorrhea.
Relative
infant doses of <10% of the maternal dose are below the level of concern for
full-term healthy infants.2 While the results in these and several other
reports suggest safety, the data are limited and breastfeeding decisions should
be made on an individual basis.
1Ilett K, Hackett P, Kristensen J,
Vaddadi K, et al: Transfer of risperidone and 9-hydroxyrisperidone into human
milk. Annals of Pharmacotherapy 2004;38 (February):273–276. From the
School of Medicine and Pharmacology, University of Western Australia, Crawley,
Australia; and other institutions.
2Bennett P. Use of the monographs
on drugs. In: Bennett P, ed. Drugs and human lactation. 2nd ed. Amsterdam:Elsevier, 1996:67–74.
From Psychiatry Drug Alerts April 2004
Breastfeeding
is often not encouraged in women taking atypical antipsychotics because of a
lack of data regarding its safety.1 In order to add to the existing
evidence (3 case reports and a review of 20 cases),2-4 olanzapine
concentrations were measured in the breast milk of a 32-year-old woman with
postpartum-onset psychosis. On the 9th postpartum day the patient presented
with auditory hallucinations; paranoid delusions; grossly disorganized
behavior; and incoherent speech. She was admitted with the infant and received
acute treatment with 5 mg haloperidol and 25 mg IM levopromazine and then 20
mg/day olanzapine. Breastfeeding was discontinued but breast milk was collected
and olanzapine concentrations were measured in the samples and in maternal
serum.
Maternal
serum olanzapine reached steady state (42 ng/mL) after 10 days at which time
the milk/plasma concentration ratio was 0.42. Based on a calculation including
milk concentrations, maternal weight and olanzapine dose, and assumed daily
milk intake, the olanzapine dose (relative to maternal dose) that would have
been transferred to the infant was at 4% of the maternal dose or about 0.011
mg/kg/day. Although this appears to be a small amount, measurement of infant
serum concentrations would be necessary to evaluate individual risk.
1Ambresin G, Berney P, Schulz P, Bryois C: Olanzapine
excretion into breast milk: a case report (letter). Journal of Clinical
Psychopharmacology 2004;24 (February):93–95. From Hôpital Psychiatrique de
Prangins, Switzerland; and other institutions.
2Goldstein D, Corbin L, Fung M: Olanzapine-exposed
pregnancies and lactation: early experience. Journal of Clinical
Psychopharmacology 2000;20(4):399–403.
3Kirchheiner J, Berghöfer A, Bolk-Weischedel D:
Healthy outcome under olanzapine treatment in a pregnant woman. Pharmacopsychiatry
2000;33:78–80.
4Ernst C, Goldberg J: The reproductive safety profile
of mood stabilizers, atypical antipsychotics and broad-spectrum psychotropics.
Journal
of Clinical Psychiatry 2002;63(Suppl 4):42–55.
Drug Trade names: haloperidol—Haldol; levopromazine—Levoprome; olanzapine—Zyprexa
From Psychiatry Drug Alerts April 2004
In a
group of 6 healthy breastfeeding infants (mean age, 2 months) whose mothers
were receiving olanzapine (Zyprexa), plasma levels of the drug were
undetectable.1
Serial
blood and milk samples were obtained from 6 mothers 5–7 times over the 12–24
hours post-dose and from 1 additional mother at a single post-dose time point.
Blood samples also were obtained from 6 of the infants; 1 mother who underwent
serial sampling did not consent to blood sampling in her infant. Olanzapine
concentrations in milk reached maximum levels about 5 hours post-dose and
maximum plasma concentrations of olanzapine were found in the mothers at 2–5
hours post-dose. Concentrations were undetectable in the infant plasma samples.
Infant exposure was calculated to be about 1% of the maternal dose, which is
substantially lower than the threshold for concern of 10%.2 Medical
examinations of 4 of the infants revealed no adverse effects of drug exposure.
Although
adjusted infant dosages were below levels of concern, mothers who want to
minimize their infant's olanzapine exposure should avoid breastfeeding when the
drug reaches maximal milk concentrations at 2–5 hours post-dose.
1Gardiner S, Kristensen J, Begg
E, Hackett L, et al: Transfer of olanzapine into breast milk, calculation of
infant drug dose, and effect on breast-fed infants. American Journal of
Psychiatry 2003;160 (August):1428–1431. From Christchurch Hospital,
Subiaco, Western Australia; and other institutions. Funded by the Women and
Infants Research Foundation; and other sources.
2Bennett P: Use of the
monographs on drugs, in Drugs and Human Lactation. Amsterdam, Elsevier,
1996:67–74.
From Psychiatry Drug Alerts October 2003
Weight Gain in Antidepressant Exposed Infants
Infants
exposed to antidepressants in breast milk showed normal weight gain during the
first 6 months of life. However, prolonged postpartum maternal depression was
associated with reduced infant weight gain.
Methods: Subjects were 78
breastfeeding mother-infant pairs. All infants were full term, and mothers had
started antidepressant therapy either during pregnancy (n=56) or within the
first 4 postpartum weeks (n=22). All women were treated with either a selective
serotonin reuptake inhibitor or venlafaxine, and 6 received a concurrent
benzodiazepine or tricyclic antidepressant. Maternal mood was assessed at
6-month intervals using a DSM-IV checklist, and infant weight was determined
from pediatrician records.
Results: Mean
infant weight at 6 months (16 lb for females, 18 lb for males) was virtually
identical to CDC published norms. When specific agents were examined
separately, none reduced infant weight gain. Notably, weight was not affected
by exposure to fluoxetine, which was previously associated with poor feeding and
diminished weight gain.
In the
group as a whole, weight gain did not differ among infants whose mothers
experienced a depressive relapse (n=26) and those who did not (n=52). However,
the infants of 11 women who had a postpartum depressive relapse lasting >2
months weighed significantly less at 6 months than infants of women who
remained euthymic or who had relatively brief relapses.
Discussion: Maternal depression may
affect infant weight gain by influencing the mother's feeding behaviors, or by
altering cortisol levels in breast milk. Results of this study suggest maternal
depression may have a larger impact than antidepressant exposure on infant
growth.
Hendrick V, Smith L, Hwang S, Altshuler L, et al: Weight gain in
breastfed infants of mothers taking antidepressant medications. Journal of
Clinical Psychiatry 2003;64 (April):410–412. From UCLA Neuropsychiatric
Institute and Hospital, Los Angeles, Calif.; and other institutions. Funded
by the NIMH; and the NIH.
Drug Trade Names: fluoxetine—Prozac; venlafaxine—Effexor
From Psychiatry Drug Alerts June 2003
Bupropion Levels in Breastfed Infants
Serum levels of bupropion (Wellbutrin)
and its metabolite, hydroxybupropion, were undetectable in 2 healthy infants of
breastfeeding mothers. Both mothers, 1 with bipolar disorder and 1 with
recurrent major depression, had previously responded to bupropion treatment but
discontinued its use during pregnancy and then resumed treatment for postpartum
depression. The bupropion dosage was 75 mg b.i.d. in the mother with bipolar
disorder, and 150 mg/day of the sustained release formulation in the mother with
recurrent depression. Both mothers received concomitant medications. Bupropion
levels were assessed in the infants at 17 and 40 weeks of age, after the mothers
had been treated for 2 and 10 weeks, respectively. Levels were below
quantifiable limits, and neither mothers nor pediatricians observed ill effects
in the infants.
It is
possible that trace amounts of bupropion were present in the infants, and a
"no-effect" level has not been determined. Data on bupropion levels
in breastfed infants is extremely limited, and the observations in these
children should not be generalized to newborns or to infants with medical
problems.
Baab S,
Peindl K, Piontek C, Wisner K: Serum bupropion levels in 2 breastfeeding
mother-infant pairs. Journal of Clinical Psychiatry 2002;63
(October):910–911. From the Case Western Reserve School of Medicine, Cleveland,
Ohio. Funded by the NIMH.
From Psychiatry Drug Alerts January 2003
Venlafaxine in Nursing Infants
A pair
of infants exposed to the atypical antidepressant venlafaxine (Effexor)
in breast milk had no detectable serum venlafaxine and had low levels of its
metabolite that did not appear to produce any adverse consequences.1
Blood
samples from 2 infant/mother pairs were analyzed for levels of venlafaxine and
its metabolite O-desmethylvenlafaxine. The pair 1 mother had begun
taking 75 mg/day venlafaxine on the day of delivery and the pair 2 mother had
taken 150 mg/day venlafaxine throughout her pregnancy. Both infants were
delivered at full-term and were exclusively breast-fed during their first 6
months. The pair 1 infant had serum drawn at 3 weeks of age, 3 hours after the
mother took her oral dose of venlafaxine. The pair 2 infant had serum drawn at
4 weeks of age, 2 hours after the mother’s dose.
At the
time of blood sampling, the mothers had serum venlafaxine concentrations of 31
and 28 ng/mL, and O-desmethylvenlafaxine of 148 and 230 ng/mL,
respectively. The infants had no detectable serum level of venlafaxine, but the
metabolite was present in both, at 16 and 21 ng/mL, respectively. The infants
have had no apparent sequelae, and appear to have developed normally during
their first year of life. The absence of venlafaxine and the presence of its
metabolite in these infants suggests that they were able to desmethylate the
venlafaxine.
There
appears to be only 1 other small series (3 infants) reported on the use of
venlafaxine in nursing mothers.2 In that report, the estimated mean
dosage of venlafaxine received by the infants was 7.6% of the maternal
weight-adjusted dose. No adverse effects were noted, but the authors cautioned
that the infant dosages were relatively high compared with those of other
antidepressants in breast milk.
1Hendrick V, Altshuler L,
Wertheimer A, Dunn W: Venlafaxine and breast-feeding (letter). American
Journal of Psychiatry 2001;158 (December):2089–2090. From Los Angeles,
Calif.
2Ilett K, et al: Distribution
and excretion of venlafaxine and O-desmethylvenlafaxine in human milk. British
Journal of Clinical Pharmacology 1998;45:459–462.
From Psychiatry Drug Alerts Febrauary 2002
A 9-week-old girl was
hospitalized for drowsiness, lethargy, and poor feeding.1
She had been delivered at 27 weeks gestation, and was discharged from the special care nursery after 8 weeks. She was fed collected breast milk after
birth, and was breastfed at home. Two weeks before re-admission, her mother had
started 300 mg/day nefazodone (Serzone) for depression. After a thorough
investigation found no apparent cause for the infant’s symptoms, nefazodone
exposure was considered, and the mother was asked to stop breastfeeding. Within
3 days, the infant’s symptoms abated. The mother was then given a single 200-mg
dose of nefazodone, and serial measurements of nefazodone and its metabolites
in blood and breast milk specimens were taken over a 12-hour period.
Pharmacokinetic
analysis showed the infant had received an average dose of 0.45% of the
mother’s weight-adjusted nefazodone dose. Although infant exposure to
antidepressants and other drugs is generally considered to be safe when the
infant dose is <10% of the maternal dose,2 this may not apply to
premature infants with immature hepatic and renal clearance mechanisms.
1Yapp P, et al: Drowsiness and
poor feeding in a breast-fed infant: association with nefazodone and its
metabolites. Annals of Pharmacotherapy 2000;34 (November):1269–1272.
From the King Edward Memorial and Princess Margaret Hospitals, Subiaco, Australia;
and other institutions. Funded by Women’s & Infants Research Foundation,
Western Australia; and Bristol-Meyers Squibb.
2Bennett P: Use of the
monographs on drugs. In: Bennett P, ed. Drugs and human lactation, 2nd
ed. Amsterdam: Elsevier Science Publishers 1996:67–74.
From Psychiatry Drug Alerts March 2001
A study in nursing mothers demonstrated that paroxetine (Paxil) is
excreted in breast milk. No paroxetine serum levels or adverse effects were
detected in the infants.
Methods:
Subjects
were 16 postpartum women receiving 10–50 mg/day paroxetine (mean, 23 mg/day)
for depression. An analysis with a limit of detection of 2 ng/mL was carried
out on 108 samples of breast milk after steady-state serum paroxetine levels
had been reached. The analysis determined 1) the time course of paroxetine
excretion into breast milk after a single oral dose, using the initial 10–20 mL
of breast milk obtained every 4–6 hours for 24 hours after drug administration;
and 2) paroxetine concentrations in breast milk, using samples obtained early
and late in the same feeding. Maternal serum samples were obtained within 2–5
hours after drug administration, and infant samples were obtained within 1–5
hours after feeding. In all infants, breast milk was the chief or exclusive
source of nutrition.
Results: Paroxetine
was detected in all breast milk samples. The milk-to-plasma ratio of paroxetine
was highly variable (0.06:1.3), depending on the timing of the sampling.
Paroxetine concentrations increased from the initial portions of breast milk to
the later portions. The time course of excretion into breast milk during the
day showed no pattern that would be useful in advising mothers to discard a
daily feeding to limit infant exposure to the medication.
No
detectable concentrations of paroxetine were found in the sera of nursing
infants. Parents reported no changes in infant behavior after the start of
treatment with paroxetine.
Discussion: Infant
exposure to paroxetine based on breast milk analysis is difficult to predict.
Laboratory results describing undetectable blood levels do not suggest a
complete absence of infant exposure to the medication, and should be
interpreted with caution.
Stowe
Z, et al: Paroxetine in human breast milk and nursing infants. American
Journal of Psychiatry 2000;157 (February):185–189. From Emory University
School of Medicine, Atlanta, Ga.; and Harvard University School of Medicine,
Cambridge, Mass. Funded in part by the NIMH; SmithKline Beecham
Pharmaceuticals; and Pfizer, Inc.
From Psychiatry Drug Alerts March 2000
A 29-year-old woman was hospitalized with postpartum depression 4 weeks after
giving birth. Against advice, she chose to continue breast-feeding while
undergoing drug therapy, but agreed to have her drug levels monitored to guard
against drug accumulation in the infant. She received 20 mg/day citalopram,
increased to 40 mg/day after 2 days. After 8 days, at steady-state levels, her
serum citalopram concentration was 99 ng/mL (within normal limits), and her
breast milk level was 205 ng/mL. After 8 more days of treatment with no change
in the dosage, the drug level in the infant was 12.7 ng/mL (corresponding to
about 5% of her mother's drug dose, on a weight-adjusted basis).
The
relatively high serum concentration in the baby along with the observation of
restless sleep within 2–3 nights after the mother started drug treatment,
resulted in a dosage reduction to 20 mg/day. At this time, formula was
substituted for the first 2 morning feedings. One week after the dosage
reduction, the serum drug concentration in the mother and infant was 49.0 ng/mL
and 4.5 ng/mL, respectively. The baby’s sleep returned to normal, and the
mother’s depressive symptoms resolved.
Discussion:
The
side effects in this infant could be explained by the high serum drug
concentration in the mother. Other SSRIs might provide a better treatment
option. Fluoxetine and sertraline may be passed into breast milk at lower
levels than citalopram, relative to maternal blood levels.
Schmidt
K, Olesen O, Jensen P: Citalopram and breast-feeding: serum concentrations and
side effects in the infant. Biological Psychiatry 2000;47 (January
15):164–165. From the Psychiatric University Hospital in Aarhus, Risskov,
Denmark.
Drug
Trade Names: citalopram—Celexa; fluoxetine—Prozac; sertraline—Zoloft
From Psychiatry Drug Alerts March 2000
Infants exposed to fluoxetine (Prozac) in breast milk gained less weight
than infants of mothers who had discontinued the medication before
breastfeeding.
Methods:
Participants in this retrospective cohort study were women (n=64) who contacted
the California Teratogen Information Service between 1989 and 1997 inquiring
about the safety of fluoxetine use during pregnancy. All subjects took
fluoxetine at some time during pregnancy, had full-term infants, and breastfed
exclusively for at least 2 weeks. Twenty-six women continued fluoxetine while
breastfeeding; 21 took 20 mg/day and none took more than 40 mg/day. Subjects
also completed a questionnaire about infant behavior; infant weight gains were
compared in both groups.
Results: Mothers
who took fluoxetine while breastfeeding had infants that were smaller at birth
than comparison infants. Postnatal weight gain, measured at an average age of
12 weeks, was about 400 g less in fluoxetine infants than in comparison infants
(p=0.05). Five infants in the fluoxetine group and 1 in the comparison group
had been admitted to a special care nursery at birth (p=0.04). The hospital
stay for each infant ranged from 1 to 4 days and did not interfere with
breastfeeding.
A
separate analysis was conducted in 30 infants who were weighed twice during the
breastfeeding period. Weight gain at the second postnatal measurement did not
differ significantly between treatment groups.
No
unusual behavior attributed to medication was reported in the fluoxetine-group
infants. However, decreased weight gain associated with mothers taking
fluoxetine while breastfeeding may be important in babies in whom weight gain
is already a concern.
Chambers C, et al: Weight gain in infants breastfed by
mothers who take fluoxetine. Pediatrics 1999;104 (November): From the
University of California, San Diego. Source of funding not stated.
From Psychiatry Drug Alerts February 2000
Antidepressants and Benzodiazepines in Nursing Infants
In an observational study, use of antidepressants or benzodiazepines during
breastfeeding was not associated with drug accumulation in infant serum. This
finding supports current American Academy of Pediatrics recommendations which
do not rule out the use of psychotropic medications in women who breastfeed.
Methods:
Investigators analyzed serum samples from 35 infants, aged 1–44 weeks,
breastfed by mothers taking SSRIs, TCAs, benzodiazepines, and, in 2 cases,
valproic acid. The mothers had sought consultation at a referral center about
taking psychotropics during breastfeeding. Twenty-five of the 35 infants were
also exposed to agents taken during their mothers’ third trimester of
pregnancy, and 10 were exposed only after birth.
Results: Of the 10
breastfeeding infants whose mothers began taking psychotropics post-delivery,
none had a detectable level of any agent or active metabolite. However, levels
of medication were detectable in 9 infants whose mothers had been taking
relatively long-acting agents during the third trimester of pregnancy. Of the 8
newborns exposed to fluoxetine in this way, 7 had detectable blood levels
within the first several weeks after delivery. Of 3 retested several weeks
later, none had detectable fluoxetine levels. Two infants had detectable
concentrations of clonazepam, including 1 infant with hyperbilirubinemia.
Clonazepam levels were not detectable in 9 other infants exposed during
pregnancy and breastfeeding. Agents that did not result in detectable blood
levels in the infants were clomipramine, desipramine, imipramine,
nortriptyline, paroxetine, sertraline, and valproic acid. None of the mothers
reported any symptoms of drug exposure in the babies.
Birnbaum
C, et al: Serum concentrations of antidepressants and benzodiazepines in
nursing infants: a case series. Pediatrics 1999;104 (July):e11. From
Massachusetts General Hospital, Boston, and other institutions. Funded by
the van Ameringen Foundation; and the National Association for Research in
Schizophrenia and Depression.
Drug
Trade Names:
clonazepam—Klonopin; clomipramine—Anafranil; desipramine—Norpramin,
Pertofrane; fluoxetine—Prozac; imipramine—Janimine, Tofranil;
nortriptyline—Aventyl, Pamelor; paroxetine—Paxil; sertraline—Zoloft;
trifluoperazine—Stelazine; valproic acid—Depakene
From Psychiatry Drug Alerts October 1999
Fluoxetine, Carbamazepine, and Breastfeeding
A 32-year-old woman with bipolar disorder took 20 mg/day fluoxetine, 300 mg
carbamazepine b.i.d., and 15 mg buspirone t.i.d. throughout her pregnancy and
postpartum period. At 42 weeks gestation, she delivered a normally developed
female infant. Against medical advice, the mother exclusively breastfed the
infant for 3 weeks. Analysis of the infant’s serum showed adult therapeutic
levels of fluoxetine on day 21 and of norfluoxetine (a metabolite) on days 13
and 21; levels of carbamazepine were very low, and buspirone was not
detectable.
At
3 weeks of age, at about the time she was switched from breast milk to formula
feeding, the infant reportedly had three 60–90-sec episodes during which her
eyes rolled back, her arms stretched out, and she became limp. The mother
related brief episodes of the baby becoming limp and unresponsive 10–12 times a
week at 4 months of age, and at 5 months of age the baby experienced peripheral
cyanosis that lasted 10–15 min. However, none of these episodes was observed by
medical personnel, and extensive inpatient evaluations of the infant were
unremarkable. At 1 year of age, she was developing normally and her earlier
seizure-like episodes remained unexplained.
Clinical Implications:
If a woman elects to breastfeed during antidepressant therapy, current evidence
supports first-line use of a tricyclic antidepressant. If she requires an agent
with major effects on serotonin, both clomipramine and sertraline are
reasonable alternatives. Although no major adverse reaction has been proven,
the FDA recommends that fluoxetine not be given to nursing mothers. The
American Academy of Pediatrics considers carbamazepine to be safe.
Brent
N, Wisner K: Fluoxetine and carbamazepine concentration in a nursing
mother/infant pair. Clinical Pediatrics 1998;37 (January):41–44. From
the Mercy Hospital of Pittsburgh, Pa.; and the Case Western Reserve University
School of Medicine, Cleveland, Ohio.
Drug
Trade Names:
buspirone—BuSpar; carbamazepine—Epitol, Tegretol; clomipramine—Anafranil;
fluoxetine—Prozac; sertraline—Zoloft
From Psychiatry Drug Alerts May 1998