Psychopharmacology Carlat Reports

Research Update

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

The Modafinils in Bipolar Depression

From The Carlat Psychiatry Report, Borderline Personality Disorder

Your patient has recovered enough from bipolar depression to leave the hospital, but not enough to return to work. He is inactive, he can’t concentrate, and it takes him 4 hours to wake up in the morning. What can you add to his regimen of lithium, lamotrigine, and lurasidone? Modafinil (Provigil) and armodafinil (Nuvigil) are wakefulness-promoting

Clinical Update

How to Choose an Antipsychotic in Schizophrenia

From The Carlat Psychiatry Report, Psychopharmacology Algorithms

It’s been over a decade since the CATIE trial changed the way we look at antipsychotic drugs. Since then, the number of second-generation antipsychotics has about doubled, and the number of clinical trials has risen even more. Antipsychotics are not all the same, though, and when it comes to schizophrenia, a few stand out in ways that can help you fin

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

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

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

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.

Article

A New Contraindication for Ambien and the Z-Hypnotics

From The Carlat Psychiatry Report, How to Talk about Medication

“Complex sleep behavior” is a euphemism for various problems that can happen after ingesting a sleeping pill. They range from cooking and emailing to driving a car or even sexual assault, all done in an amnestic state that is not recalled upon awakening. In 2007 the FDA placed warnings about these behaviors on all medications approved for insomnia,

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

Research Update

Lithium in Geriatric Depression

From The Carlat Psychiatry Report, Side Effects Part I

REVIEW OF: Buspavanich P et al, J Affect Disord 2019;251:136–140 TYPE OF STUDY: Prospective, non-randomized controlled trial Augmentation with lithium has long been established as an effective strategy for refractory depression, but how does it fare in geriatric patients? There is a dearth of evidence on lithium in the geriatric population, which

Article

Evaluating the Mortality Risks of Antipsychotics in Children and Youths

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

Topics: Antipsychotics | Psychopharmacology | Schizophrenia

There are reports of increased mortality from antipsychotics in older adults. Now, we have a paper showing increased mortality in children, adolescents, and young adults aged 5–24 years. Given the frequent use, both on- and off-label, of antipsychotics, does this change how we use them? And if so, how? What we already know In 2005, the FDA added a

Article

Prescription CBD Is Available, But Are We Ready to Use It?

From The Carlat Psychiatry Report, Deprescribing

Topics: Anxiety | Cannabidiol | Free Articles | Psychopharmacology

Your patient comes in with a new medication on his list: CBD oil. He started taking it for anxiety and wants to know if it’s safe. You hedge, explaining that there is limited information available on unregulated products, but the patient is persistent. He says CBD oil is available as a prescription, and wonders if you could write one for it. Cannab

Expert Q&A

Deprescribing Medication

From The Carlat Psychiatry Report, Deprescribing

Topics: Deprescribing | Psychopharmacology

There’s no shortage of information on prescribing medications, but when and how do we stop them? The Bruyere Deprescribing Guidelines Research Team is a group of clinicians and researchers who’ve set out to answer those questions. They’ve recently published 5 deprescribing guidelines, 3 of which are for psychiatric medications: benzodiazepines, an

Article

Ask the Editor: Three Significant Food Interactions with ADHD Medications

From The Carlat Psychiatry Report, Working With Transgender Patients

Topics: Free Articles | Practice Tools and Tips | Psychopharmacology

Each month, Editor-in-Chief Chris Aiken, MD, gives advice on a different practice challenge. If you have a question you’d like Dr. Aiken to answer, please send an email to AskTheEditor@thecarlatreport.com. Dr. Aiken won’t be able to answer all questions received but will pick one each month that is of general interest. Dear Dr. Aiken: Patients of

Article

Treating Chronic Pain When There’s Addiction: A Primer

From The Carlat Addiction Treatment Report, Pain and Addiction

Topics: Addiction | Practice Tools and Tips | Psychopharmacology | Registered Articles

It can be challenging to manage chronic pain, even more so when our patients suffer from addiction. We can find ourselves walking a tightrope between the risk of relapse due to the inadequate treatment of pain, and the risk of relapse due to the use of opioid analgesics. Since our mission is to minimize suffering and optimize functioning while helpin