Typically, patients will report food craving and binging. Weight gain is rapid in the first three months, more gradual over the following year, then often plateaus. Rapid initial weight gain is correlated with greater eventual cumulative weight gain. FDA definition of weight gain is ≥7% increase in weight from baseline. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Clonidine is an alpha-2 agonist that has no abuse potential, does not worsen tics, and does not cause insomnia. However, it’s less effective than stimulants and has a delayed onset of effect (two to four weeks); it is often added to a stimulant to prevent insomnia. Clonidine may be used as a second-line option for opioid detoxification if buprenorphine or methadone are not available. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Omega-3 fatty acids form the lipid bilayers of cell membranes, and supplementing our natural dietary supply may have psychological and cardiological benefits. Based on the limited data available, the best use of omega-3 fatty acids (particularly 1–2 g with at least 60% EPA) is as an adjunct in the treatment of unipolar and bipolar depression. There is not enough evidence to recommend omega-3 fatty acids in other psychiatric disorders at this time. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Lurasidone offers some advantages, including no need for titration, once-daily dosing, relatively low-moderate metabolic profile, and relatively low QT prolongation risk. It is also one of five antipsychotics approved for bipolar depression (along with cariprazine, lumateperone, olanzapine/fluoxetine, and quetiapine). However, its use is limited by the need to administer with at least 350 calories of food, potential for drug interactions, and side effects including sedation, akathisia, and EPS. In clinical practice, you might lump lurasidone with the other second-generation antipsychotics that cause little weight gain, such as aripiprazole and ziprasidone. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Paroxetine is the least favored SSRI due to its side effect profile (greatest sexual side effects, weight gain, sedation, constipation), drug interaction profile, and risk for discontinuation syndrome. However, its wide range of FDA anxiety indications leads some clinicians to favor it for patients with significant anxiety From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

A rare but potentially life-threatening drug reaction presenting with muscle rigidity (“lead pipe”), hyperthermia, and altered mental status. May present similarly to serotonin syndrome although may be less acute in onset (within days vs hours). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

ECT is one of the most effective treatments in psychiatry, but cognitive side effects understandably make patients reluctant to try it. We should recommend it to any patient with severe treatment-resistant depression or psychosis. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Memantine’s indication (moderate to severe dementia only) may limit its use, but it does boast a unique mechanism of action and has some data to support its usefulness as an augmenter of donepezil. Many prescribers put the majority of their dementia patients on a combination of one of the cholinesterase inhibitors and memantine; we recommend adding memantine when dementia has progressed to the moderate or severe level, possibly earlier. There’s no clinical benefit to using the more expensive XR version. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Mirtazapine tends to cause weight gain and sedation, but no sexual dysfunction or GI side effects, and thus is particularly useful in depressed patients with anxiety or insomnia, those who have had sexual side effects with other antidepressants, and those who may benefit from appetite stimulation (eg, elderly, cancer patients). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Impairment of some aspect of sexual functioning, including low libido, anorgasmia, decreased sensation, erectile dysfunction, or delayed or retrograde ejaculation (in men). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).