Suvorexant is an orexin receptor antagonist, and as such it treats insomnia differently from existing agents (though lemborexant and daridorexant have since followed in its footsteps). Other than a new mechanism of action, suvorexant doesn’t have any clear advantages. It is no more effective than benzos or Z-drugs, and it has a similar abuse liability. We’re concerned that next-day impairment is a potential side effect at the highest approved dose of 20 mg, particularly since sleepless patients may decide on their own to take even higher doses. It’s not a first-line hypnotic. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Sertraline is a good first-line SSRI option for many patients due to its range of indications, flexible dosing, low drug interaction potential, and relative tolerability. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Thyroid augmentation is often chosen for patients with depression-associated lethargy and fatigue. The usual formulation used is T3 (Cytomel). Response rates in clinical trials are mixed and only modest, but thyroid augmentation is inexpensive and well tolerated and may be worth a try, especially for patients on tricyclics (the evidence is less impressive for SSRI augmentation). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Trihexyphenidyl is an anticholinergic medication that is less favored than benztropine because it must be dosed TID and is only available in oral formulations. Use as a second-line option. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Brexanolone is a novel, fast-acting option that is given intravenously for patients with severe postpartum depression. However, its utility is limited by the lengthy infusion (60 hours) in a health care setting, potential for severe reactions and associated need for close monitoring, high cost ($34,000 for the drug alone, plus costs associated with providers and health care facilities), and lack of follow-up data beyond 30 days. Zuranolone, a new orally available neurosteroid, provides a safer and easier option for this indication. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Valproic acid is the go-to antimanic agent for acute manic episodes, featuring faster onset of response and better adverse effect profile compared to lithium, fewer drug interactions than carbamazepine, and efficacy for rapid cycling and relapse prevention. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

When a benzodiazepine is appropriate for use (short-term; minimal risk of abuse), we consider lorazepam to be a firstline agent. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Due to its longer half-life, clonazepam causes fewer breakthrough symptoms compared to alprazolam when used for anxiety. May also work as a good short-term hypnotic, although development of dependence and long half-life limit this use. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Successful marketing has convinced the public that “low T” is a public health scourge, leading to over-prescribing of testosterone for patients who don’t need it. Prescribe it only for men with demonstrably low testosterone levels and accompanying symptoms. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Temazepam has the advantages of a short half-life and no active metabolites, and is therefore less likely to cause nextday sedation. It’s a decent first-line agent for insomnia if a benzodiazepine is appropriate for use. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).