Antidepressants Carlat Reports

Clinical Update

From The Carlat Psychiatry Report, Telepsychiatry

If your practice is anything like mine, trazodone is your go-to hypnotic. As an antidepressant, it’s an afterthought, dismissed as ineffective or intolerable since its release in 1981. Four decades and over 200 clinical trials later, it’s a good time to see if we’ve missed any opportunities in this forgotten antidepressant. How trazodone worksTra

Clinical Update

Antidepressants: When Dosage Matters

From The Carlat Psychiatry Report, Thyroid and Mental Illness

Topics: Antidepressants | Depression | SSRIs

When it comes to dosing antidepressants, it’s often assumed that more is better. While this is true for a few meds, most second-generation antidepressants don’t clearly work better at higher doses. In this article, I’ll review the evidence on antidepressant dose-response relationships and the optimal dose ranges for some antidepressants. First-ge

Research Update

Psilocybin vs Escitalopram for Depression

From The Carlat Psychiatry Report, Overdiagnosis

REVIEW OF: Carhart-Harris R et al, New Engl J Med 2021;384(15):1402–1411 STUDY TYPE: Randomized controlled trial Psilocybin is, among other things, a serotonin 2A agonist responsible for the psychedelic properties of magic mushrooms. Back in 1960, Sandoz (now Novartis) began marketing psilocybin to enhance the effects of psychotherapy, but produ

Research Update

Comparison of GI Side Effects of Antidepressants

From The Carlat Psychiatry Report, Therapy

REVIEW OF: Oliva V et al, Prog Neuropsychopharmacol Biol Psychiatry 2021;109:110266 TYPE OF STUDY: Meta-analysis of placebo-controlled trials Antidepressants often cause gastrointestinal (GI) side effects, but it’s not clear which ones are the worst actors. A recent meta-analysis helps to clarify the picture. The investigators searched the li

Research Update

Antidepressants Harm Some With Bipolar Depression

From The Carlat Psychiatry Report, Metabolism and Mental Health

Topics: Antidepressants | Bipolar Depression | Bipolar Disorder

REVIEW OF: Ghaemi SN et al, J Clin Psychiatry 2021;82(1):19m13136 Study TYPE: Randomized, double-blind, placebo-controlled trial Antidepressants are controversial in bipolar depression, in part because we don’t have enough well-designed studies to clarify their role. The most rigorous trials have come up negative, and many of the positive ones s

Expert Q&A

How to Come Off a Psych Med Part 2: Antidepressants, Stimulants, and Benzos

From The Carlat Psychiatry Report, Stopping Psych Meds Part 2

Topics: Antidepressants | Benzodiazepines | Deprescribing | Withdrawal

TCPR: Before we talk about your experience with tapering medications, tell us about the population you work with.Dr. Gupta: In the past, I worked at the Connecticut Mental Health Center for Yale University. There I saw patients with pretty serious mental illness: mainly psychotic disorders, severe trauma, addictions, and serious psychosocial stressors

How to Select an SSRI

From The Carlat Psychiatry Report, Practical Psychotherapy

On March 14, 2012, Lexapro became the last SSRI to lose its patent, closing the book on a quarter century of science and marketing that changed and sometimes confused the way we think about antidepressants. Now that the unpublished studies have come to light and the incentives to favor one drug over another have dried up, it’s a good time to take a so

Clinical Update

Keeping Up With Trintellix

From The Carlat Psychiatry Report, Mood and Menopause

In a previous report (TCPR, Feb 2019), we summarized the data on cognitive effects associated with vortioxetine (Trintellix). We found that vortioxetine produced impressive results for cognition based on improvement on the Digital Symbol Substitution Test (DSST), and gave Takeda Pharmaceuticals high marks for choosing to compare vortioxetine to duloxeti

Expert Q&A

Mood and Menopause

From The Carlat Psychiatry Report, Mood and Menopause

TCPR: When does perimenopausal depression tend to start?Dr. Nonacs: It’s during the transition into menopause that women are most vulnerable to depression. And that transition can actually take quite a while, like 5–7 years. TCPR: How does it present?Dr. Nonacs: Often they’ve had a history of depression, but have done fairly well up to this point

Expert Q&A

The Psychopharmacology Algorithm Project

From The Carlat Psychiatry Report, Psychopharmacology Algorithms

TCPR: What would be the biggest change in practice if psychiatrists followed your algorithms?Dr. Osser: One area is bipolar depression. This is a disorder where there is an exceptionally large deviation between what the evidence says and what people are doing, especially when it comes to antidepressants. They are still being used rampantly, even in pati

Research Update

Optimal Antidepressant Doses in Major Depression

From The Carlat Psychiatry Report, Bipolar II

Review of: Furukawa TA et al, Lancet Psychiatry;2019;6(7):601–609 Type of study: Systematic review and meta-analysis Most antidepressants do not have a linear response curve. In other words, the benefits level off as the dose goes up. If the dose gets too high, the side effects start to outweigh those diminishing returns. What’s not clear is whe

Research Update

An Answer for Psychotic Depression

From The Carlat Psychiatry Report, Inflammation and Depression

REVIEW OF: Flint AJ et al, JAMA 2019;322(7):622–631 TYPE OF STUDY: Randomized, placebo-controlled trial Psychotic features in depression indicate a more severe form of the disease, with a higher risk of hospitalization and double the rate of disability compared with non-psychotic depression. A combination of an antipsychotic and an antidepressant is

Research Update

Anti-Inflammatories as Antidepressants?

From The Carlat Psychiatry Report, Mental Health Apps

Topics: Antidepressants | Depression | Inflammation | Novel Medications | Treatment-Resistant Depression

Review of: Köhler-Forsberg O et al, Acta Psych Scand 2019;139(5):404–419 Study Type: Meta-analysis of randomized controlled trials Several lines of evidence suggest that chronic inflammation contributes to depression. For example, markers of inflammation tend to be elevated in depressed patients, and inflammatory syndromes elicit depressive sym

Article

Mirtazapine Augmentation: Running Low on Rocket Fuel

From The Carlat Psychiatry Report, How to Talk about Medication

Adding mirtazapine (Remeron) to a serotonergic antidepressant is a popular augmentation strategy. When added to venlafaxine, the combo was thought to possess a particularly potent synergy that Stephen Stahl called “California Rocket Fuel.” However, the strategy has failed in a handful of new studies, some of them much larger than the original data.

Ask The Editor

Is Paxil the Best SSRI for Anxiety?

From The Carlat Psychiatry Report, How to Talk about Medication

Dear Dr. Aiken: Your review of Paxil’s risks in the May issue failed to mention a benefit that’s unique to this drug. Isn’t it the best SSRI for anxiety? Dr. Aiken: Paroxetine’s (Paxil’s) reputation as the anti-anxiety SSRI got off to a running start. It was first launched for panic disorder in 1996, two years before its approval for depres

Article

l-Methylfolate for Depression: Costly Mistake or Good Thinking?

From The Carlat Psychiatry Report, Side Effects Part II

Folate (Vitamin B9) has a long track record as a low-cost, low-risk augmentation strategy in depression. It’s also available in a more expensive form, l-methylfolate (Deplin), that promises better results but at a premium price. So, is the cost worth it? Folate pathwaysFolate (the natural form of folic acid) is a B vitamin that’s important in psych

Article

Trintellix and Cognition: A Closer Look

From The Carlat Psychiatry Report, Dark and Light Therapy

Topics: Antidepressants

You may have been hearing a lot of buzz about vortioxetine (Trintellix) and cognition. The FDA recently allowed a labeling change with this antidepressant that mentions specific benefits in cognitive symptoms of depression. Depressed patients tell us all the time how bad their memory is, and their concerns are valid. On average, depression impairs cogni

Research Update

Is Ketamine Just Another Opiate?

From The Carlat Psychiatry Report, Deprescribing

Topics: Antidepressants | Depression | Ketamine | Opioids | Research Update

Review of: Williams NR et al, Am J Psychiatry 2018;175:1–11 Type of study: Double-blind, placebo-controlled, crossover study Ketamine’s rapid antidepressant effects have now been demonstrated in over two dozen double-blind, placebo-controlled trials, but how it works is less clear. For many years, NMDA receptor antagonism was thought responsib

Article

Treatment-Resistant Depression: Some Introductory Tips

From The Carlat Psychiatry Report, Treatment-Resistant Depression

Topics: Antidepressants | Bipolar Disorder | Depressive Disorder | Registered Articles

Treatment-resistant depression (TRD) has a fairly low barrier of entry. Failure of 2 full antidepressant trials—lasting 6 weeks at a minimally effective dose—is enough to qualify. In this month’s issue of TCPR, we’ll highlight pharmacologic advances that are underutilized and debunk a few that are unlikely to be effective for TRD. But first, we

Article

Antidepressant Augmentation Strategies: A Basic Guide

From The Carlat Psychiatry Report, Treatment-Resistant Depression

Topics: Antidepressants | Free Articles

Here’s a common scenario. You have a patient who has tried three or four antidepressants over the years; all have been somewhat effective at least initially, but eventually that effectiveness waned. Let’s imagine that the patient you’re seeing now is on antidepressant number 4, Lexapro, at a solid 20 mg dose. You could always keep pushing the d