Lavender essential oil is a reasonable option in patients who have not responded to FDA-approved treatments for generalized anxiety disorder (GAD) or in patients who request a natural alternative. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Magnesium supplementation is purported to improve symptoms of ADHD, insomnia, or anxiety, but supporting or convincing evidence is lacking, and most get the magnesium they need from their diet. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Paliperidone is the active metabolite of risperidone. In comparison with its parent compound, paliperidone has the advantages of no drug-drug interactions, an easy transition to several long-acting injectable formulations, and a unique FDA indication for schizoaffective disorder. Disadvantages include more QT interval prolongation than risperidone, more tachycardia, possibly more EPS, and the same amount of hyperprolactinemia. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Methamphetamine is highly addictive when used in its crystal form (“crystal meth”), because it causes an immediate and intense high when snorted or smoked. Its use is generally not recommended. Watch the television show “Breaking Bad” if you’re not convinced! From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Ambien is the original Z-drug, having been initially FDA approved in 1992. It is a good hypnotic that can also help with sleep maintenance, particularly in the ER formulation. The lower-dose sublingual version (Intermezzo) has a shorter duration of action and can be taken in the middle of the night—but we recommend using cheaper generic zaleplon instead for middle-of-the-night awakening. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Esketamine is the s-enantiomer of ketamine, given as a nasal spray. It is only modestly effective for treatment-resistant depression and suicidality; its main advantage is its speed of onset, which is typically 24 hours. FDA requirements mandate that it be given in a health care facility and that patients be monitored for two hours after each treatment. Most clinicians consider it less effective than the unapproved intravenous use of ketamine. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Topiramate is a reasonable off-label choice for alcohol use disorder and antipsychotic-induced weight gain. Otherwise, relegate it to the “try when out of other ideas” category. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Zuranolone is a novel, fast-acting neurosteroid, similar to brexanolone. Rather than intravenously, it’s given orally for patients with severe postpartum depression (PPD). This new drug provides ease of use, good tolerability, rapid action, and significant improvement in patients with PPD. We recommend using it in severe PPD when rapid response is critical. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Like the first norepinephrine reuptake inhibitor for ADHD, atomoxetine, viloxazine has no abuse potential and is less likely than stimulants to cause insomnia, anxiety, or tics. However, it is generally less effective than stimulants and takes longer to work. It’s unclear if it has any advantage, and unlike atomoxetine, there’s no option for a cheaper generic. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Namzaric combines donepezil and memantine in a single capsule. It is helpful for patients who are already on this combination regimen but who have trouble taking two pills. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).