Serotonergic meds protocol

Selective Serotonin reuptake inhibitors used in the treatment of emotional inflexibility,
depression and anxiety:

• Prozac (fluoxetine) • Zoloft (sertraline) • Paxil (paroxetine) • Luvox (fluvoxamine) • Celexa (citalopram) • Lexapro (escitalopram)
Some other anti-depressants, which may also help with ADHD:
• Wellbutrin (buproprion): reg tabs 75, 100; SR 100,150, 200; XL 150, 300 • Tofranil (imipramine)
Some other antidepressants, which may also help with sleep:
• Remeron (mitrazapine) • Tofranil (Imipramine) Note: Before beginning any medication, parents should have a clear understanding of the diagnosis, purpose of treatment, types of available treatments, “off-label” use of medications which are not specifically approved by the FDA for use in pediatrics, known efficacy of available treatments, known side effects of available treatments, expected outcome with no treatment, expected efficacy of suggested treatment, expected side effects of suggested treatment, confidentiality, emergency procedures, monitoring and follow-up. If they do not feel that they have given informed consent, then they should not administer the medication.

1. Starting medication and dose: _______________________________________________. I recommend beginning medications and making any dose changes on Friday nights or Saturday mornings, so that parents can be sure there are no side effects over the weekend. 2. Adjustments: Side effects tend to happen early, usually within days of each dose change. Although peak benefits happen late, usually after a few months, you may see the beginning of benefits earlier, sometimes even within the first week. After one week at each dose, compare baseline ratings before medication with updated ratings: a. “Looking good”: If benefits are optimal (2s and 3s are down to 0s and 1s) and side effects are insignificant (numbers on the bottom half of the page have not gone up), then stay with that dose. b. “Too low”: If benefits are less than optimal and side effects are insignificant, then increase the dose by an amount equal to the starting dose. c. “Hopefully just an adjustment”: If benefits are optimal but there are significant side effects, call me. We will probably decrease the dose by ¼-½ the starting dose. Call me again after this adjustment if side effects do not lessen each day. d. “No good”: If benefits are less than optimal and there are significant side effects, call me. Remembering that side effects can happen before benefits, we will either decrease the dose by ½ (and give the maximum tolerated dose a chance to work) or just stop and consider trying something else. Daniel G. Shapiro, M.D.
Developmental and Behavioral Pediatrics
11705 Magruder Lane
Rockville, Maryland 20852
Telephone: 301-881-6855
Fax: 301-881-9849


Child’s name: ____________________________Grade: ___________ Year: ______________ Person completing this form: ________________________Relation to child: ________________ Dear Parents, Teachers, and Student: Thank you very much for your help. It is so important to conduct this medication trial in a careful and controlled fashion. Please complete the table below. Record observations for the week indicated. Your comments in narrative form are also very helpful. On the back, please record the date and elaborate on any side effects and benefits. Please call me if you have any questions or concerns. Thank you. How often did you notice the following? 0=not at all, 1=just a little, 2=often, 3=very often
DATE (week
Inflexibility/ frustration intolerance
Increased/ decreased appetite (circle one) Restless,hyper,manic,impulsive,distractible



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