L-tryptophan is an amino acid that is eventually converted to serotonin. The evidence base to support using L-tryptophan in depression is extremely limited, but more and more patients are turning to it, especially in combination “serotonin boost” products being marketed today. We recommend sticking to the serotonergic agents we know to be safe and effective: SSRIs and SNRIs. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Loxapine is being rediscovered as a well-tolerated first-generation antipsychotic—it is of medium potency, and causes minimal EPS or weight gain. An oldy-but-goody alternative to second-generation antipsychotics. 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).

Gabapentin used to be considered a non-addictive medication for anxiety and for alcohol dependence, but we now know it may be misused and diverted for its euphoriant effect. If monitored closely, it can still be helpful for anxiety and insomnia, especially if your patient also suffers from one of the approved indications—such as neuropathic pain and restless legs syndrome. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Fluphenazine is an effective, inexpensive first-generation antipsychotic with a long history of experience and use, but clinical utility is limited in some patients due to EPS. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Fluoxetine’s wide spectrum of indications and its long track record make it a go-to SSRI, and it is often favored in patients who could use some activation. Its main disadvantage is its high potential for drug interactions. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Aripiprazole is a good choice for minimizing risk of weight gain and metabolic side effects, but beware of akathisia. Large number of indications and reports of success at a variety of doses make it difficult to predict dosing for individual patients. 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).

Ramelteon is a melatonin receptor agonist. Compared to other hypnotics, ramelteon poses a lower risk for respiratory depression and hangover effect (morning grogginess). It’s a good agent to have in your bag of tricks, but consider the possibility of rare hormonal effects. Also consider that over-the-counter melatonin (which ramelteon mimics) may do the same job, possibly at a lower price. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Trifluoperazine, like thiothixene (Navane), is an effective older agent with similar potency to haloperidol or fluphenazine; however, given all our antipsychotic options, it sees only rare use these days. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).