Pharmacology Carlat Reports | Carlat Publishing

Clinical Update

From The Carlat Psychiatry Report, Mind-Gut Connection

Lamotrigine is FDA approved as maintenance treatment for bipolar disorder—that is, for delaying episodes of depression, hypomania, or mania. However, it is not approved for active depression or mania—which has given it a reputation as a “light” mood stabilizer. For patients who appreciate tolerability, that’s a good thing, but it isn’t the f

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

Research Update

Mood Stabilizers: What You Don’t Know Can Hurt Them

From The Carlat Psychiatry Report, Mood and Menopause

Topics: | | | | | | | | | | | | | | | | | | | | | | | | Antipsychotics Aripiprazole Asenapine Bipolar Depression Bipolar Disorder Bipolar II Cariprazine Lithium Lurasidone Mania Medication adherence Mood Stabilizers olanzapine Oxcarbazepine Pharmacology Pharmacology Tips Psychopharmacology Psychopharmacology Tips Quetiapine Research Research Update Risperidone safety Saphris Side Effects

Review of: Bai Y et al, J Clin Psychopharmacol 2020;40(2):167–179 STUDY TYPE: Combined meta-analysis and literature review of placebo-controlled trials Medication adherence is an ongoing struggle in bipolar disorder, and it’s compounded by the fact that our patients often don’t advertise their non-adherence. While numbers vary, reviews general

Research Update

Guanfacine ER for Adults With ADHD?

From The Carlat Psychiatry Report, Mood and Menopause

Review of: Iwanami A et al, J Clin Psychiatry 2020;81(3):19m12979 Study type: Randomized, double-blind, placebo-controlled trial Stimulants are rapid, safe, and effective first-line treatments for many adults with ADHD. However, there are inevitably patients for whom stimulants are not indicated or tolerated—those with arrhythmias or stimulant use d

Expert Q&A

Who Should Get Lithium?

From The Carlat Psychiatry Report, When to Use Lithium

TCPR: Lithium has been called the gold-standard treatment in bipolar disorder. Why is it not used more often? Dr. Rybakowski: That is a paradox. On the one hand, lithium is accepted as a first-line treatment for bipolar disorder, but it is also greatly underutilized. And I think there are two main reasons. One is aggressive promotion of branded mood st

Research Update

Two Augmentation Strategies Compared in Bipolar I

From The Carlat Psychiatry Report, When to Use Lithium

Review of: Missio G et al, Trials 2019;20(1):608 STUDY TYPE: Randomized, open-label controlled trial It’s rare to see full recovery in bipolar I disorder with a single medicine, so we often depend on some combination of mood stabilizers and/or antipsychotics. Even then, weight gain and metabolic problems are deal-breakers. Some experts favor the c

Clinical Update

Oxcarbazepine: Close, but no Cigar

From The Carlat Psychiatry Report, Bipolar II

You are selecting a mood stabilizer for a 29-year-old woman with mania. If it works, she’ll need to take it long term, but with adherence rates hovering around 50% in this illness, that’s not a likely prospect. The FDA-approved options are not very high on tolerability, but what about oxcarbazepine? Oxcarbazepine (Trileptal) is often used in bipo

News of Note

Lumateperone and lemborexant

From The Carlat Psychiatry Report, Bipolar II

Two new psychiatric medications were approved in the final days of 2019. One is the first of its kind, an antipsychotic with minimal dopaminergic blockade: lumateperone (Caplyta). The other is lemborexant (Dayvigo), a variation on the hypnotic suvorexant (Belsomra). Lumateperone (Caplyta)Though classified as an atypical antipsychotic, lumateperone is u

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

Highlights

Highlight From This Issue

From The Carlat Psychiatry Report, Bipolar II

In bipolar disorder, oxcarbazepine is slightly better tolerated than carbamazepine, but less effective. While its medical risks are different, they are by no means safer than carbamazepine’s. Its drug interactions can be a problem as well. On average, higher doses of second-generation antidepressants do not bring greater recoveries in major depress

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

Pharmacology for GAD: Complex Choices

From The Carlat Psychiatry Report, Adult ADHD

Review of: Slee A et al, Lancet 2019;393(10173):768–777 Study Type: Network meta-analysis With over 2 dozen choices, how do we pick a medication for generalized anxiety disorder (GAD)? The authors of this network meta-analysis sought to answer this question. Network meta-analysis allows researchers to gauge treatments that haven’t been directly c

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

News of Note

A New Treatment for Bipolar Depression

From The Carlat Psychiatry Report, Side Effects Part II

On May 28, 2019, cariprazine (Vraylar) became the fourth atypical antipsychotic to receive FDA approval for bipolar depression. The approval was based on two randomized controlled trials involving 1,051 patients and lasting 6–8 weeks. These studies grouped patients into fixed doses from 0.75–3 mg/day. The sweet spot seems to be 1.5 mg/day, which was

Article

Esketamine Gets FDA Approval

From The Carlat Psychiatry Report, Side Effects Part I

Topics: Depression | Depressive Disorder | Esketamine | Pharmacology | Treatment-Resistant Depression

On March 5, 2019, the FDA approved esketamine (Spravato) nasal spray as add-on therapy to traditional antidepressant medications for treatment-resistant depression (TRD). In this article, I will describe the events that led to esketamine’s development, review the data submitted to the FDA, and discuss what the future might hold for esketamine. Backgr

Article Links

Risk Evaluation and Mitigation Strategy (REMS) Programs

From The Carlat Psychiatry Report, Side Effects Part I

Topics: Depression | Depressive Disorder | Esketamine | Pharmacology | Treatment-Resistant Depression

Certain psychiatric treatments require both the healthcare provider and patient to enroll in a Risk Evaluation and Mitigation Strategy (REMS) program before they are administered. Below are links to enroll: Brexanolone (Zulresso) http://www.zulressorems.com/ Buprenorphine-based therapies (Suboxone, Subutex) https://www.samhsa.gov/medication-assi

Expert Q&A

Medication Side Effects: Nausea, Sweating, and Dry Mouth

From The Carlat Psychiatry Report, Side Effects Part I

Topics: Pharmacology | Pharmacology Tips | Side Effects

TCPR: What’s the best way to manage side effects: lower the dose of the current medication or use an antidote? Dr. Mago: If the patient can stay well on a lower dose, that’s usually my first approach. Most side effects are dose related. TCPR: For the rest of this interview, we’ll assume that lowering the dose or changing the medication was not

News of Note

A New Dopamine and Norepinephrine Reuptake Inhibitor for Excessive Sleepiness

From The Carlat Psychiatry Report, Side Effects Part I

Topics: Novel Medications | Pharmacology | Sleep Apnea | Sleep Disorders

Solriamfetol (Sunosi), a new dopamine and norepinephrine reuptake inhibitor (DNRI), has been approved by the FDA “to improve wakefulness in adult patients with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea.” The medication has never been studied in psychiatry, but is likely to have important psychiatric effects