Psychopharmacology Carlat Reports

Clinical Update

What Gets in the Way of Antidepressants?

From The Carlat Psychiatry Report, ADHD

When patients don’t respond to an antidepressant, it’s a good idea to step back and look for anything that might be getting in the way. Major stress, substance use, medication nonadherence, anxiety, and medical and psychiatric comorbidities are high on that list, but recent research has added more possibilities that we’ll review in this article.

Clinical Update

Quetiapine Reconsidered

From The Carlat Psychiatry Report, Psychotic Depression

It is the best of drugs; it is the worst of drugs. Quetiapine (Seroquel) has benefits in some disorders that are unmatched by other medications, but it is also one of the most difficult antipsychotics to tolerate. In this article, I’ll look at where this medication fits and whether its numerous off-label uses are justifiable, including PTSD, generaliz

Clinical Update

Intranasal Esketamine: New Hope for Suicidal Patients?

From The Carlat Hospital Psychiatry Report, Psychiatric Emergencies

It’s likely your patients have asked you about esketamine. The buzz is that it’s a rapid-acting miracle cure for suicidal depression. Dr. Thomas Insel, former director of NIMH, declared that ketamine “might be the most important breakthrough in antidepressant treatment in decades” (www.nimh.nih.gov/about/directors/thomas-insel/blog/2014/ketamine

Expert Q&A

Combination Treatment for Schizophrenia

From The Carlat Hospital Psychiatry Report, Psychiatric Emergencies

CHPR: You recently published a study on the use of adjunctive medications in patients with schizophrenia (Stroup TS et al, JAMA Psychiatry 2019;76(5):508–515). Your findings were provocative as you found that adjunctive medications often help improve patients’ outcomes, yet many clinicians avoid polypharmacy because of concern that patients will exp

Expert Q&A

Medications for Depression

From The Carlat Child Psychiatry Report, Depression in Children and Adolescents

CCPR: You recently published an article reviewing the placebo-controlled trials done over the past 10 years on depression in kids (Ignaszewski MJ and Waslick B, J Child Adolesc Psychopharmacol 2018;Epub ahead of print). Can you tell us about your findings? Dr. Ignaszewski: Historically, there’s been a lot of controversy about the effectiveness of a

Expert Q&A

Real-World Alcohol Use Disorder Treatment

From The Carlat Addiction Treatment Report, Alcohol Use Disorder

Topics: Alcohol use disorder | Comorbidity | Dual diagnosis | Psychopharmacology | Psychotherapy

CATR: Please tell us about yourself. Dr. Petrakis: I’m an addiction psychiatrist, professor at Yale School of Medicine, and the Chief of Mental Health for the VA Connecticut Healthcare System. I have several research focuses, one of which is the treatment of individuals with comorbid psychiatric illness and alcohol use disorder (AUD). CATR: We kno

Clinical Update

Medications for Alcohol Use Disorder: An Overview

From The Carlat Addiction Treatment Report, Alcohol Use Disorder

Topics: Alcohol use disorder | Medication | Psychopharmacology

Alcohol use disorder (AUD) is the most common substance use disorder by far, with a lifetime prevalence of nearly 30%. It is also vastly undertreated; less than 20% of people with AUD ever receive treatment (Grant BF et al, JAMA Psychiatry 2015;72(8):757–766). To make matters worse, there are only three FDA-approved medications for AUD: disulfiram, ac

Research Update

Meds for Alcohol Use Disorders

From The Carlat Addiction Treatment Report, Smoking Cessation

Topics: Alcohol use disorder | Naltrexone | observational study | Psychopharmacology

REVIEW OF: Heikkinen M et al, Addiction 2021;116(8):1990–1998 STUDY TYPE: Cohort study In the US, only 9% of patients diagnosed with alcohol use disorder (AUD) are prescribed AUD medication (Kranzler HR and Soyka M, JAMA 2018;320(8):815–824). A Swedish study provides evidence that further illuminates the potential harms from this lack of treat

Research Update

Gabapentin Enacarbil XR Efficacy Less Than Expected for AUD

From The Carlat Addiction Treatment Report, Legal Issues in Addiction Medicine

Review of: Falk DE et al, Alcohol Clin Exp Res 2019;43(1):158–169 Gabapentin enacarbil extended-release (GE-XR) (Horizant) is an extended-release version of gabapentin. GE-XR is a prodrug, meaning that once ingested it is metabolized into gabapentin. It is currently approved for treatment of postherpetic neuralgia and restless legs syndrome. It di

Article

How to Treat Tardive Dyskinesia

From The Carlat Psychiatry Report, Esketamine

Your patient is a 56-year-old male who recovered from a difficult-to-treat depression 4 years ago after quetiapine was added to his citalopram. As he talks, you notice that his fingers are tapping in a rapid, random pattern and his feet are wiggling. When questioned, he explains, “I just do that when I’m anxious.” Should you stop the antipsychotic

Article

Antipsychotic Maintenance: How Long is Enough?

From The Carlat Psychiatry Report, Esketamine

Your 58-year-old patient started risperidone to augment lithium 2 years ago. It got her out of a severe mania, and she has stayed well since then. Now she’s worried about long-term risks and wondering if it’s time to come off. Augmentation with an atypical antipsychotic may offer rapid relief from mania and depression, but antipsychotics’ potenti

Clinical Update

Trazodone: The Forgotten Antidepressant

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

How to Treat ADHD in Bipolar Disorder

From The Carlat Psychiatry Report, Bipolar Disorder

Topics: | | | | | | | | | | | | | | | | | | ADHD Alpha Agonists Amphetamines ArModafinil Atomoxetine Attention Deficit Hyperactivity Disorder Bipolar Disorder Bipolar II Comorbidity Guanfacine methylphenidate Modafinil Nuvigil Pharmacology Provigil Psychopharmacology Psychopharmacology Tips stimulant Stimulants

Patients with bipolar disorder often present with cognitive complaints. Our October 2021 issue laid out a diagnostic plan for these symptoms, and in this article, I’ll cover some treatment approaches for patients with a DSM-based ADHD-bipolar comorbidity (ie, the ADHD symptoms began in childhood and persist after the mood episodes have stabilized).

Research Update

Brexpiprazole Ineffective in Mania

From The Carlat Psychiatry Report, Mood Disorders

REVIEW OF: Vieta E et al, J Psychopharmacol 2021;35(8):971–982 TYPE OF STUDY: Phase III randomized controlled trials Brexpiprazole is FDA approved in schizophrenia and as an adjunct for major depression and is one of the better-tolerated antipsychotics. Like aripiprazole, it is a partial D2 and 5-HT1A agonist. Unlike most antipsychotics, brexpiprazo

Clinical Update

Buspirone: Still Effective After All These Years?

From The Carlat Psychiatry Report, Stopping Psych Meds Part 1

When buspirone was released in 1986, it was advertised as providing “a different kind of calm.” Unfortunately, physicians and their patients weren’t ready to accept the kind of calm that required several weeks to take effect, when punchier, quicker benzos were the standard route to tranquility. Although buspirone is FDA approved for generalized an

Research Update

How to Switch Antipsychotics

From The Carlat Psychiatry Report, Stopping Psych Meds Part 1

Review of: Takeuchi H and Remington G, J Psychopharmacol 2020;34(8):914–919 Type of study: Meta-analysis of randomized controlled trials Antipsychotic switching is a routine part of schizophrenia care, but what’s the best way to go from one medication to another? This article compared three strategies: 1) abruptly stopping the old antipsychotic an

Clinical Update

How to Use Lamotrigine

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

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

Research Update

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

From The Carlat Psychiatry Report, Mood and Menopause

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