Psychopharmacology Tips Carlat Reports

Clinical Update

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

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

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

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

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

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

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

Expert Q&A

Medication Side Effects Part II: Weight Gain, Akathisia, Hair Loss, and Orthostasis

From The Carlat Psychiatry Report, Side Effects Part II

Editor’s note: In the June/July issue, Dr. Mago shared a sampling of his strategies for nausea, sweating, and dry mouth. We wrap up that conversation here with a few more tips on managing side effects. Weight gain TCPR: What’s your approach to antipsychotic-induced weight gain? Dr. Mago: Prevention is better than treatment. So, when possible, we

Article

Opioid Treatment Options

From The Carlat Addiction Treatment Report, Opioid Addiction

Topics: Free Articles | Practice Tools and Tips | Psychopharmacology Tips | Substance Abuse

Opioid use disorder (OUD) treatment can be tricky, in part because it doesn’t respond well to detox and counseling-only approaches. The overwhelming majority of people relapse after such attempts, or even become more vulnerable to overdose because of decreased tolerance after detoxing. And the trajectory in this country is worsening—in 2016, we aver

Article

New Stimulants: From Remixed Amphetamines to Bedtime Ritalin

From The Carlat Psychiatry Report, Drug Metabolism

Topics: ADHD | Psychopharmacology Tips

You may have noticed that a confusing array of new stimulants has been approved in the last few years. Since 2012, there have been five new amphetamines and two new methylphenidates. What are these preparations? Are any of them worth prescribing to your patients? To prepare you for the promotional downpour that’s likely to accompany all this repackagi

Article

Harnessing Beneficial Drug Interactions

From The Carlat Psychiatry Report, Drug Metabolism

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

It’s nice when we can get our patients better with a single medication, but that’s not always possible. Sometimes the right combination of meds can do the trick, but studies of polypharmacy are scarce. In this article we dig through that research, small and limited as it is, to highlight a few useful combinations where the drug interaction can benef

Expert Q&A

Effects of Drug Interactions

From The Carlat Psychiatry Report, Drug Metabolism

Topics: Practice Tools and Tips | Psychopharmacology Tips

TCPR: We’re seeing a lot of computer alerts for drug interactions. Which ones should we pay attention to? Dr. Sandson: The two issues to pay attention to are toxicity and loss of efficacy. Toxicity is the bigger concern, particularly if the drug has a “narrow therapeutic index,” where modest differences in the level can have dangerous effects. Li