Tetrabenazine was the original VMAT inhibitor brought to market and approved for the treatment of Huntington’s disease. It’s an off-label alternative to deutetrabenazine and valbenazine for treating tardive dyskinesia (TD). Although it’s much less expensive, it requires more frequent dosing and may have a higher likelihood of causing depression. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

May be particularly useful for individuals whose depression is associated with fatigue and poor concentration. Absence of sexual side effects and weight gain make this an appealing option for many depressed patients. Although not effective for anxiety disorders, it is effective for the anxiety that often accompanies depression. The seizure risk is not a concern for most patients when dosed appropriately From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Flibanserin, marketed as the “pink Viagra,” is mildly effective for enhancing sexual desire, but with potentially significant side effects and precautions regarding alcohol use around the time of administration. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Metformin is a medication for type 2 diabetes that increases insulin sensitivity and decreases appetite. It’s somewhat effective for antipsychotic-induced weight gain (average of 3 kg weight loss) and might work better if started prophylactically as a way to prevent excessive weight gain in the first place. It’s quite safe and well tolerated (with some GI side effects) and is becoming a standard add-on treatment in patients taking clozapine or olanzapine. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Adderall contains 75% dextroamphetamine and 25% levoamphetamine. This ratio of amphetamine isomers is effective but is probably the most abused and diverted of all prescription stimulants. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Desvenlafaxine is the active metabolite of venlafaxine, and it has some minor advantages in terms of drug interactions, ease of dosing, and longer half-life. One disadvantage is lack of FDA approval for anxiety disorders. At least for depression, since desvenlafaxine is now available in a low-cost generic version, some clinicians prefer it over venlafaxine XR. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Daytrana is helpful for kids who, for whatever reason, cannot use any of the wide variety of oral stimulant preparations. Otherwise, we don’t recommend it due to high cost, lag time for onset of effect, and the side effect of rash, which is pretty common and unpleasant. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Nefazodone was once popular due to the lack of sexual side effects, but is now rarely used due to rare hepatic effects. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Bottom Line: Lamotrigine is a good choice for maintenance treatment of bipolar disorder, especially to prevent depressive episodes. It has a good side effect profile. Its main disadvantage is the very slow titration schedule recommended to decrease the risk of Stevens-Johnson syndrome—as well as its ineffectiveness in the treatment of manic episodes. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Orthostatic hypotension (OH) is caused by blood pooling in the lower extremities when people stand up, causing less blood flow to the brain and consequent dizziness. Usually caused by medications that block the alpha-1 receptors, which are responsible for telling the body to constrict blood vessels (and maintain blood pressure) after standing up. Patients will report feeling faint when they get up, and occasionally a sense of the room spinning (vertigo). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).