Rivastigmine is no longer the only cholinesterase inhibitor available in patch form, but it or the new donepezil patch may be advantageous for patients who refuse or have difficulty swallowing medication. Otherwise, we generally consider rivastigmine a second-line agent due to the need for twice-daily dosing and its high rate of nausea and vomiting. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Valbenazine was the first of the VMAT inhibitors to be approved for the treatment of tardive dyskinesia (TD) in 2017. Its advantage over off-label tetrabenazine is less frequent dosing (once daily) and less likelihood of causing depression. However, it is extremely expensive—about $7,000/month as opposed to $700/month for tetrabenazine. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Triazolam gained notoriety as the benzodiazepine that may have caused President George Bush to faint at a state dinner in 1992. It is rarely used due to the higher likelihood for adverse effects (anterograde amnesia, psychiatric disturbances) compared to other benzos. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Like other Z-drugs, eszopiclone is an effective hypnotic with less potential for dependence than the benzodiazepines. Dosing is simple and, apart from the bitter aftertaste, its rapid onset and long duration of action make it well accepted among patients. As with all sedatives/hypnotics, nightly use should be discouraged. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Vardenafil doesn’t offer any benefits compared to sildenafil, which has more data in the psychiatric setting and more clinical experience. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Dexmedetomidine is an alpha-2 agonist (think clonidine) that is used at higher doses intravenously (as Precedex) for ICU sedation. This new lower-dose sublingual formulation is approved for acute agitation associated with schizophrenia and bipolar disorder. However, its high cost, absence of data beyond 24 hours, potential adverse effects, and need for patient cooperation for sublingual administration limit its utility. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Doxepin may be a good agent to put in your arsenal, particularly for those patients in whom you want to avoid benzodiazepines or Z-drugs. Now that the low-dose (3 and 6 mg) generic version of Silenor is available, price is less of a limitation. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

We have fewer data for tadalafil in the psychiatric setting; however, compared to other agents in the class, its long duration of action may improve spontaneity, and the lack of interaction with meals may offer advantages. Tadalafil is an especially good choice for men who have both prostatic hypertrophy and erectile dysfunction (ED). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Perphenazine, first introduced in 1957, is an older first-generation agent that enjoyed a big boost in popularity after the 2005 CATIE trial found it to be as effective as most second-generation agents with minimal weight gain or metabolic problems. It has become a favorite go-to antipsychotic for many clinicians—an effective, well-tolerated, and inexpensive alternative to second-generation antipsychotics. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Bremelanotide (marketed as the “female Viagra”) is a melanocortin receptor agonist that is modestly effective in increasing sexual desire in women, though it doesn’t affect sexual functioning. Disadvantages include the fact that it requires self-injection and carries a 40% rate of nausea as a side effect. It’s worth trying in some patients, but don’t expect miracles. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).