Psychopharmacology

Expert Q&A

Medications for Depression

Topics: adolescents | Child Psychiatry | children | Depression | pediatric | Psychopharmacology | teens | treatment

CCPR: You recently published an article reviewing the ­placebo-controlled trials done over the past 10 years on depression in kids (Ignaszewski MJ and Waslick B, J Child Adolesc Psychopharmacol 2018;Epub ahead of print). Can you tell us about your findings? Dr. Ignaszewski: Historically, there’s been a lot of controversy about the effectiveness of a

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Research Update

Gabapentin Enacarbil XR Efficacy Less Than Expected for AUD

Topics: Addiction | Addiction Treatment | Alcohol | Alcohol use disorder | Alcoholism | Clinical practice | extended-release | Medication | Novel Medications | Pharmacology | Psychopharmacology | Research Update

Review of: Falk DE et al, Alcohol Clin Exp Res 2019;43(1):158–169 Gabapentin enacarbil extended-release (GE-XR) (Horizant) is an extended-release version of gabapentin. GE-XR is a prodrug, meaning that once ingested it is metabolized into gabapentin. It is currently approved for treatment of postherpetic neuralgia and restless legs syndrome. It di

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Article

How to Treat Tardive Dyskinesia

Topics: Amantadine | Austedo | Deutetrabenazine | Ginkgo | Ingrezza | Keppra | Levetiracetam | Melatonin | Psychopharmacology | Psychopharmacology Tips | Side Effects | Tardive dyskinesia | Valbenazine | Vitamin B6 | Vitamin E | VMAT2 Inhibitors

Your patient is a 56-year-old male who recovered from a difficult-to-treat depression 4 years ago after quetiapine was added to his citalopram. As he talks, you notice that his fingers are tapping in a rapid, random pattern and his feet are wiggling. When questioned, he explains, “I just do that when I’m anxious.” Should you stop the antipsychotic

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Article

Antipsychotic Maintenance: How Long is Enough?

Topics: Antidepressant Augmentation | Antidepressants | Antipsychotics | Bipolar Disorder | Deprescribing | Depression | Depressive Disorder | Mania | Metabolic syndrome | Mood Stabilizers | olanzapine | Psychopharmacology | Psychopharmacology Tips | Risperidone | Side Effects | Tardive dyskinesia

Your 58-year-old patient started risperidone to augment lithium 2 years ago. It got her out of a severe mania, and she has stayed well since then. Now she’s worried about long-term risks and wondering if it’s time to come off. Augmentation with an atypical antipsychotic may offer rapid relief from mania and depression, but antipsychotics’ potenti

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Clinical Update

How to Choose an Antipsychotic in Schizophrenia

Topics: Antipsychotics | Aripiprazole | Cariprazine | Clozapine | Negative Symptoms | olanzapine | Psychopharmacology | Psychopharmacology Tips | Psychosis | Risperidone | Schizophrenia

It’s been over a decade since the CATIE trial changed the way we look at antipsychotic drugs. Since then, the number of second-generation antipsychotics has about doubled, and the number of clinical trials has risen even more. Antipsychotics are not all the same, though, and when it comes to schizophrenia, a few stand out in ways that can help you fin

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Expert Q&A

The Psychopharmacology Algorithm Project

Topics: Antidepressant Augmentation | Antidepressants | Antipsychotics | Bipolar Disorder | Bupropion | Depression | Depressive Disorder | Escitalopram | Lamictal | Lamotrigine | Lithium | Mood Stabilizers | olanzapine | Psychopharmacology | Psychopharmacology Tips | Wellbutrin

TCPR: What would be the biggest change in practice if psychiatrists followed your algorithms?Dr. Osser: One area is bipolar depression. This is a disorder where there is an exceptionally large deviation between what the evidence says and what people are doing, especially when it comes to antidepressants. They are still being used rampantly, even in pati

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Clinical Update

Oxcarbazepine: Close, but no Cigar

Topics: Bipolar Disorder | Carbamazepine | Mania | Mood Stabilizers | Oxcarbazepine | Pharmacology | Psychopharm Myths | Psychopharmacology

You are selecting a mood stabilizer for a 29-year-old woman with mania. If it works, she’ll need to take it long term, but with adherence rates hovering around 50% in this illness, that’s not a likely prospect. The FDA-approved options are not very high on tolerability, but what about oxcarbazepine? Oxcarbazepine (Trileptal) is often used in bipola

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News of Note

Lumateperone and lemborexant

Topics: Antipsychotics | Belsomra | Caplyta | Dayvigo | Hypnotics | Lemborexant | Lumateperone | News of Note | Orexin | Pharmacology | Psychopharmacology | Suvorexant

Two new psychiatric medications were approved in the final days of 2019. One is the first of its kind, an antipsychotic with minimal dopaminergic blockade: lumateperone (Caplyta). The other is lemborexant (Dayvigo), a variation on the hypnotic suvorexant (Belsomra). Lumateperone (Caplyta)Though classified as an atypical antipsychotic, lumateperone is u

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Highlights

Highlight From This Issue

Topics: Bipolar Disorder | Carbamazepine | Mania | Mood Stabilizers | Oxcarbazepine | Pharmacology | Psychopharm Myths | Psychopharmacology

In bipolar disorder, oxcarbazepine is slightly better tolerated than carbamazepine, but less effective. While its medical risks are different, they are by no means safer than carbamazepine’s. Its drug interactions can be a problem as well. On average, higher doses of second-generation antidepressants do not bring greater recoveries in major depress

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Article

Mirtazapine Augmentation: Running Low on Rocket Fuel

Topics: Antidepressant Augmentation | Antidepressants | Depression | Depressive Disorder | Mirtazapine | Pharmacology | Pharmacology Tips | Psychopharm Myths | Psychopharmacology | Psychopharmacology Tips | SSRIs | Treatment-Resistant Depression | Venlafaxine

Adding mirtazapine (Remeron) to a serotonergic antidepressant is a popular augmentation strategy. When added to venlafaxine, the combo was thought to possess a particularly potent synergy that Stephen Stahl called “California Rocket Fuel.” However, the strategy has failed in a handful of new studies, some of them much larger than the original data.

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Article

A New Contraindication for Ambien and the Z-Hypnotics

Topics: FDA Warnings | Hypnotics | Insomnia | News of Note | Practice Tools and Tips | Psychopharmacology | Psychopharmacology Tips | Sleep

“Complex sleep behavior” is a euphemism for various problems that can happen after ingesting a sleeping pill. They range from cooking and emailing to driving a car or even sexual assault, all done in an amnestic state that is not recalled upon awakening. In 2007 the FDA placed warnings about these behaviors on all medications approved for insomnia,

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Ask The Editor

Is Paxil the Best SSRI for Anxiety?

Topics: Antidepressants | Anxiety | Anxiety Disorder | Generalized Anxiety Disorder | Panic Disorder | Pharmaceutical Industry | Pharmacology | Pharmacology Tips | Practice Tools and Tips | Psychopharm Myths | Psychopharmacology | Psychopharmacology Tips | PTSD | Social Anxiety Disorder | SSRIs

Dear Dr. Aiken: Your review of Paxil’s risks in the May issue failed to mention a benefit that’s unique to this drug. Isn’t it the best SSRI for anxiety? Dr. Aiken: Paroxetine’s (Paxil’s) reputation as the anti-anxiety SSRI got off to a running start. It was first launched for panic disorder in 1996, two years before its approval for depres

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Article

l-Methylfolate for Depression: Costly Mistake or Good Thinking?

Topics: Antidepressants | CAM Treatments | Deplin | Depression | Depressive Disorder | Folate | Folic Acid | l-methylfolate | methylfolate | Natural Medications | Nutrition | Pharmacology | Pharmacology Tips | Psychopharmacology | Psychopharmacology Tips | Treatment-Resistant Depression

Folate (Vitamin B9) has a long track record as a low-cost, low-risk augmentation strategy in depression. It’s also available in a more expensive form, l-methylfolate (Deplin), that promises better results but at a premium price. So, is the cost worth it? Folate pathwaysFolate (the natural form of folic acid) is a B vitamin that’s important in psych

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News of Note

A New Treatment for Bipolar Depression

Topics: Antipsychotics | Atypical Antipsychotics | Bipolar Depression | Bipolar Disorder | Depression | News of Note | Pharmacology | Psychopharmacology

On May 28, 2019, cariprazine (Vraylar) became the fourth atypical antipsychotic to receive FDA approval for bipolar depression. The approval was based on two randomized controlled trials involving 1,051 patients and lasting 6–8 weeks. These studies grouped patients into fixed doses from 0.75–3 mg/day. The sweet spot seems to be 1.5 mg/day, which was

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Research Update

Lithium in Geriatric Depression

Topics: Depression | Depressive Disorder | Geriatric Psychiatry | Lithium | Psychopharmacology | Treatment-Resistant Depression

REVIEW OF: Buspavanich P et al, J ­Affect Disord 2019;251:136–140 TYPE OF STUDY: Prospective, non-randomized controlled trial Augmentation with lithium has long been established as an effective strategy for refractory depression, but how does it fare in geriatric patients? There is a dearth of evidence on lithium in the geriatric population, which

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Article

Evaluating the Mortality Risks of Antipsychotics in Children and Youths

Topics: Antipsychotics | Psychopharmacology | Schizophrenia

There are reports of increased mortality from antipsychotics in older adults. Now, we have a paper showing increased mortality in children, adolescents, and young adults aged 5–24 years. Given the frequent use, both on- and off-label, of antipsychotics, does this change how we use them? And if so, how? What we already know In 2005, the FDA added a

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Article

Prescription CBD Is Available, But Are We Ready to Use It?

Topics: Anxiety | Cannabidiol | Free Articles | Psychopharmacology

Your patient comes in with a new medication on his list: CBD oil. He started taking it for anxiety and wants to know if it’s safe. You hedge, explaining that there is limited information available on unregulated products, but the patient is persistent. He says CBD oil is available as a prescription, and wonders if you could write one for it. Cannab

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Expert Q&A

Deprescribing Medication

Topics: Deprescribing | Psychopharmacology

There’s no shortage of information on prescribing medications, but when and how do we stop them? The Bruyere Deprescribing Guidelines Research Team is a group of clinicians and researchers who’ve set out to answer those questions. They’ve recently published 5 deprescribing guidelines, 3 of which are for psychiatric medications: benzodiazepines, an

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Article

Ask the Editor: Three Significant Food Interactions with ADHD Medications

Topics: Free Articles | Practice Tools and Tips | Psychopharmacology

Each month, Editor-in-Chief Chris Aiken, MD, gives advice on a different practice challenge. If you have a question you’d like Dr. Aiken to answer, please send an email to AskTheEditor@thecarlatreport.com. Dr. Aiken won’t be able to answer all questions received but will pick one each month that is of general interest. Dear Dr. Aiken: Patients of

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Article

Treating Chronic Pain When There’s Addiction: A Primer

Topics: Addiction | Practice Tools and Tips | Psychopharmacology | Registered Articles

It can be challenging to manage chronic pain, even more so when our patients suffer from addiction. We can find ourselves walking a tightrope between the risk of relapse due to the inadequate treatment of pain, and the risk of relapse due to the use of opioid analgesics. Since our mission is to minimize suffering and optimize functioning while helpin

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