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with a propensity for seizures (eg, previous head injury, alcohol withdrawal) Loss of libido and erectile, ejaculatory, and orgasmic dysfunction are fairly common and can compromise compliance Trazodone rarely causes priapism, which requires treatment within 12 hours (epinephrine 1:1000 injected into the corpus cavernosum) Delirium, agitation, and mania are infrequent complications Sudden discontinuation of some of these drugs can produce cholinergic rebound, manifested by headaches and nausea with abdominal cramps Overdoses of TCAs are often serious because of the narrow therapeutic index and quinidine-like effects (see 38) 3 Monoamine oxidase inhibitors The MAO inhibitors are generally used as third-line drugs for depression (after a failure of SSRIs, TCAs, or the atypical antidepressants) because of the dietary and other restrictions required (see below and Table 25 7) They should be considered third-line drugs for refractory panic disorder and depression; however, this has changed since MAO inhibitor skin patches (selegilene) have become available They deliver the MAO inhibitor to the bloodstream bypassing the gastrointestinal tract so that dietary restrictions are not necessary in the lowest dosage strength (6 mg/24h) Oral MAO inhibitors are administered in gradual stepwise dosage and may be given in the morning or evening, depending upon their effect on sleep They tend to take effect in a fairly low dosage range (Table 25 8) Blood levels are not congruent with therapeutic response The MAO inhibitors commonly cause symptoms of orthostatic hypotension (which may persist) and sympathomimetic effects of tachycardia, sweating, and tremor Nausea, insomnia (often associated with intense afternoon drowsiness), and sexual dysfunction are common Trazodone, 25 75 mg orally at bedtime, may ameliorate the MAO-induced insomnia Central nervous system effects include agitation and toxic psychoses Dietary limitations (Table 25 7) and abstinence from drug products containing phenylpropanolamine, phenylephrine, meperidine, dextromethorphan, and pseudoephedrine are mandatory for MAO-A type inhibitors (those marketed for treatment of depression), since the reduction of available MAO leaves the patient vulnerable to exogenous amines (eg, tyramine in foodstuffs) Treatment for a resultant hypertensive crisis has been the same as for pheochromocytoma (see 26), but there have been reports of success with nifedipine, 10 mg chewed and placed under the tongue, normalizing blood pressure in 1 5 minutes The restrictions on the proscribed foodstuffs and sympathomimetic drugs are in effect during treatment and for.

1 Cheese, except cream cheese and cottage cheese and fresh yogurt 2 Fermented or aged meats such as bologna, salami 3 Broad bean pods such as Chinese bean pods 4 Liver of all types 5 Meat and yeast extracts 6 Red wine, sherry, vermouth, cognac, beer, ale 7 Soy sauce, shrimp paste, sauerkraut MAOI, monoamine oxidase inhibitor

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This section introduces you to the main technical features of Mac OS, from its initial release in 1984 through the present. These features are contrasted with similar features of the UNIX operating system. The heart of any computer operating system is the kernel. Broadly speaking, you can view Mac OS as a collection of cooperating system components, distributing system services between system components. In contrast, Mac OS X is based on a microkernel design. An important element of the Macintosh system, although not technically part of the traditional notion of an operating system, is the User Interface Toolbox, or simply the Toolbox. The Toolbox, which was originally located in the ROM but now resides on disk, is a set of functions that programs access to construct the graphical elements of a program and interact with core system components. The Toolbox gives the Macintosh its unique appearance and feel. It defines and implements routines that handle user interface components like dialog boxes, windows, and menus; it also provides foundational drawing routines, as well as sound, printing, memory management, and file services. By providing a fairly complete set of controls, the Toolbox encouraged all developers to use the same controls, thus making applications similar in look and function. Each group of related routines are arranged within Managers. For example, memory management functions are part of the Memory Manager; file functions are part of the File Manager. Figure C.2 shows a high-level view of the Macintosh system.

Usual Daily Oral Dose (mg) 5 40 100 300 300 600 20 30 50 150 20 10 150 250 150 200 100 100 250 150 200 150 200 100 200 100 150 15 40 45 60 20 30 6 (skin patch) 150 225 40 15 45 3003 300 100 300 75 200 Usual Daily Maximum Dose (mg) 80 300 600 50 200 40 20 300 400 250 300 300 300 300 150 60 90 50 12 Sedative Effects1 <1 1 2 1 <1 <1 <1 4 2 3 1 4 3 4 2 1 Anticholinergic Effects1 <1 <1 <1 1 <1 1 1 4 2 3 1 3 3 2 2 3 Cost for 30 Days Treatment Based on Maximum Dosage2 $32040 $23760 $14400 $16380 $16320 $7950 $8430 $6960 $20040 $15720 $13500 $9000 $21960 $11160 $13140 $53100 $10800 $14250 $49267

Drug SSRIs Fluoxetine (Prozac, Sarafem) Fluvoxamine (Luvox) Nefazodone (Serzone) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Amitriptyline (Elavil) Amoxapine (Asendin) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil) Maprotiline (Ludiomil) Nortriptyline (Aventyl, Pamelor) Protriptyline (Vivactil) Monoamine oxidase inhibitors Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline transdermal (Emsam) Other compounds Venlafaxine XR (Effexor) Duloxetine (Cymbalta) Mirtazapine (Remeron) Bupropion XL (Wellbutrin XL) Bupropion SR (Wellbutrin SR) Trazodone (Desyrel) Trimipramine (Surmontil)

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Cost per Unit $267/20 mg $264/100 mg $160/200 mg $273/20 mg $272/100 mg $265/40 mg $281/20 mg $116/150 mg $167/100 mg $147/75 mg $150/100 mg $100/100 mg $122/50 mg $093/75 mg $146/50 mg $295/10 mg $060/15 mg $095/10 mg $1642/6 mg patch

225 60 45 4503 4004 400 200

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