Solriamfetol is a wakefulness promoter with a different mechanism of action from modafinil and armodafinil. Patients may ask you about it given all the TV ads, but time will tell how it compares with these more established (and cheaper) agents. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Pimavanserin is the only antipsychotic with virtually no effect on dopamine receptors. It is the only approved medication for psychosis in Parkinson’s disease, but we do not yet know if it has any efficacy advantages over quetiapine, which has generally been the go-to antipsychotic for this syndrome. Its lack of weight gain is a side effect advantage, but there are some concerns about increases in hospitalization and higher mortality in patients with Parkinson’s disease psychosis. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Tasimelteon is a melatonin receptor agonist approved for non-24-hour sleep-wake disorder (N24SWD), which occurs primarily in blind people. Due to its high price (even for the new generic version), you may want to consider ramelteon instead. While ramelteon hasn’t been studied in patients with N24SWD, it’s reasonable to try because it is so similar pharmacologically yet much more affordable. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

SAMe is a natural methyl donor important in neurotransmitter synthesis and function. Several clinical studies (lasting up to 42 days) have shown that taking SAMe is more effective than placebo and appears to be as effective as tricyclic antidepressants, though the studies were limited in various ways. Consider using it for those patients with mild to moderate depression who are interested in using alternative therapies, or as an augmentation strategy in partial responders. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Propranolol has several uses in psychiatry, including performance anxiety, drug-induced tremor, and akathisia. Some clinicians favor it as an “as needed” drug for a variety of anxiety issues, especially when benzos are contraindicated. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Armodafinil is an effective wake-promoting agent with some potential for abuse and for drug interactions. It lasts a bit longer than modafinil. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

A rare but potentially life-threatening drug reaction that can range from mild to severe. Presents with muscle rigidity (typically hypertonicity, hyperreflexia, clonus), hyperthermia, and altered mental status. While very similar to neuroleptic malignant syndrome (NMS) in presentation, serotonin syndrome typically has a much more acute onset (drastic change from baseline within three to four hours). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Prazosin is an alpha-1 antagonist (FDA approved for hypertension) that has become popular as a treatment for PTSD-associated insomnia/nightmares. More recent studies have cast doubt on its efficacy for nightmares, but many clinicians still believe it is useful. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Guanfacine is an alpha-2 agonist that has no abuse potential, does not worsen tics, and does not cause insomnia. However, it is less effective than stimulants and has a delayed onset of effect (two to four weeks). Guanfacine ER is now available in generic and is easier to use than IR. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Asenapine’s claim to fame is its availability in both sublingual and skin patch formulations, so it’s a good choice for patients who can’t or don’t want to swallow a pill. Mouth numbness (Saphris), sedation, dizziness, akathisia, weight gain, and potential for allergic reaction are significant liabilities. Not recommended for first-line use.