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Clinical Update

From The Carlat Psychiatry Report, ADHD

Every day we are faced with prescribing dilemmas that don’t have ready answers. Instant or extended release? Brand or generic? With food or without? How should we adjust dosing to account for drug interactions, age, gender, ethnicity, or genetic testing results? Our new textbook Prescribing Psychotropics: From Drug Interactions to Pharmacogenetics is

Research Update

Vyvanse for Sluggish Cognitive Tempo in ADHD

From The Carlat Psychiatry Report, ADHD

Topics: Cognition | Side Effects | Vyvanse

REVIEW OF: Adler LA et al, J Clin Psychiatry 2021;82(4):20m13687 STUDY TYPE: Randomized placebo-controlled trial Patients with ADHD often also struggle with sluggish cognitive tempo (SCT). Characteristics of SCT include being prone to daydreaming, being easily bored, feeling “spacey” or lethargic, and not processing information quickly or accu

Clinical Update

Tricyclic Antidepressants: When and How to Use Them

From The Carlat Psychiatry Report, Race and Mental Health

Topics: Antidepressants | Dosing | Side Effects | Treatment-Resistant Depression | Weight gain

Tricyclics have been used in psychiatry since the 1950s, when imipramine was introduced as the first mass-marketed antidepressant. Fluoxetine and the other SSRIs largely supplanted the tricyclics in the 1990s, but these medications still have their uses. There are two kinds of tricyclics: Tertiary amines—the “originals” Secondary amines—t

Research Update

Sublingual Atropine Drops and Clozapine-Induced Drooling

From The Carlat Hospital Psychiatry Report, Catatonia

Topics: Atropine | Clozapine | Drooling | hypersalivation | Side Effects

REVIEW OF: Mubaslat O and Lambert T, Psychopharmacology (Berl) 2020;237(10):2905–2915 STUDY TYPE: Randomized placebo-controlled trial Excessive salivation or drooling is one of the more troublesome side effects of clozapine, occurring in up to 80% of patients. It is embarrassing for patients and is a factor in drug discontinuation. Aspiration pn

In Brief

IM Olanzapine Plus Benzodiazepines: Safe or Unsafe?

From The Carlat Hospital Psychiatry Report, Agitation

Topics: Antipsychotics | Benzodiazepines | olanzapine | Psychotic Agitation | Side Effects

The Eli Lilly warning followed reports of 160 adverse events, including 29 fatalities, linked to IM olanzapine/IM benzodiazepine combinations from January 2004 to September 2005 (Marder SR et al, J Clin Psychiatry 2010;71(4):433–441). Looking closely at these cases, it is unclear that this medication combination actually caused the fatalities. Many of

Clinical Update

Battle of the Bulge: Obesity and Antipsychotic-Induced Weight Gain

From The Carlat Hospital Psychiatry Report, Metabolic Side Effects

Topics: | | | | | | | | | | | | | | | | | | | | Aripiprazole Benzphetamine Bupropion Diabetes Diethylpropion Exercise Insulin resistance Liraglutide Metabolic syndrome Metformin Naltrexone olanzapine Phendimetrazine Phentermine Samidorphan Semaglutide Side Effects Topiramate Waist circumference Weight gain Ziprasidone

Many psychiatric medications cause weight gain, including mood stabilizers, antidepressants, and especially antipsychotics. Most weight gain secondary to antipsychotic use occurs in the first 6 months of therapy, so it’s important to monitor weight closely and intervene early in a patient’s treatment. We counsel patients at every visit about healthy

Expert Q&A

Weight Gain and Metabolic Side Effects

From The Carlat Hospital Psychiatry Report, Metabolic Side Effects

CHPR: Dr. Marder, can you please tell us about your work? Dr. Marder: Sure. My work has focused on pharmacologic and nonpharmacologic approaches to improving the outcomes of serious mental illnesses, particularly schizophrenia. I’m very interested in ways to combine psychosocial interventions with pharmacological approaches and to reduce adverse side

Research Update

SSRIs vs SNRIs in Pediatric Anxiety Disorders: Which Are More Tolerable?

From The Carlat Child Psychiatry Report, Substance Use in Children and Adolescents

REVIEW OF: Mills JA and Strawn JR, J Am Acad Child Adolesc Psychiatry 2020;59(11):1240–1251 STUDY Type: Meta-analysis For children with anxiety disorders and OCD, SSRIs produce faster and greater improvement than SNRIs (Strawn JR et al, J Am Acad Child Adolesc Psychiatry 2018;57(4):235–244.e2). Unfortunately, adverse effects slow down our dose

Research Update

Which Medications Have the Lowest Risk of Side Effects?

From The Carlat Child Psychiatry Report, Mood Disorders in Children and Adolescents

REVIEW OF: Solmi M et al, World Psychiatry 2020;19(2):214–232 Adverse effects are important considerations when choosing psychotropic medications, especially in children and adolescents. This study pooled available research to compare the safety profiles of various psychotropics used in the pediatric population. The authors screened thousands of st

Research Update

Varenicline and Bupropion: Soaring Again With EAGLES?

From The Carlat Addiction Treatment Report, Medical Issues in Addiction Practice

Review of: Anthenelli RM et al, Lancet 2016;387(10037):2507–2520 Varenicline (Chantix) and bupropion (Zyban and others) are effective treatments for tobacco use disorder, but their use (and sales) took a big hit in 2009 when the FDA slapped both with black box warnings linking them to psychiatric complications, including suicidal ideation. Although

Clinical Update

An Unexpected Opioid: Loperamide Misuse

From The Carlat Addiction Treatment Report, Stimulant Use Disorder

Topics: Free Articles | Opioids | Over the counter medication | safety | Side Effects

Loperamide, a common antidiarrheal available at pharmacies across the country, has unexpectedly become one of the latest in a growing trend of over-the-counter medications being repurposed for recreational use. Over the past 10 years, the broader public has discovered that supratherapeutic doses of loperamide can result in opioid-like euphoric effects.

Clinical Update

“What About the Implant, Doc?” Appraising Various Formulations of Buprenorphine

From The Carlat Addiction Treatment Report, Opioid Use Disorder Treatment

With other epidemics in the world dominating our attention, let’s not forget the epidemic of opioid-related deaths. Unlike the current viral epidemic, the opioid epidemic is eminently treatable. The figure on page 3 shows the reduction in heroin overdoses in Baltimore, MD, as increasing numbers of patients received opioid agonist treatment (Schwartz R

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

Expert Q&A

Thyroid Augmentation in Bipolar Disorder

From The Carlat Psychiatry Report, Thyroid and Mental Illness

TCPR: When do you use thyroid augmentation in bipolar disorder?Dr. Kelly: It may be useful for treatment-resistant bipolar depression, and I emphasize treatment-resistant because that is where the empiric support lies. Now, the evidence is not rock-solid, but when it comes to treatment-resistant bipolar depression we don’t have much else to draw on ex

Research Update

Anticholinergic-Associated Cognitive Impairment in Schizophrenia

From The Carlat Psychiatry Report, Thyroid and Mental Illness

Topics: Cognition | Negative symptoms of schizophrenia | Schizophrenia | Side Effects

REVIEW OF: Joshi YB et al, Am J Psychiatry 2021;178(9):838–847 STUDY TYPE: Cross-sectional study Schizophrenia is associated with impaired cognition. Medications with anticholinergic properties, including antipsychotics, benztropine (Cogentin), and antidepressants, can worsen this problem and may confer increased risk of dementia. What we don’t kn

In Brief

Lybalvi: The Diet Olanzapine

From The Carlat Psychiatry Report, Schizophrenia

Lybalvi is a new combo pill that aims to overcome the dreaded metabolic effects of olanzapine by pairing it with the opioid antagonist samidorphan. Patients still gain weight on Lybalvi, though not as much as they do on olanzapine. In the three controlled trials that compared the two drugs, the weight gain on Lybalvi was 5 lb less at six months, 3 lb le

Research Update

Sleepwalking on Antipsychotics and Lithium

From The Carlat Psychiatry Report, Bipolar Disorder

REVIEW OF: Gouverneur A et al, Br J Clin Pharmacol 2021;87:3971–3977 STUDY TYPE: Retrospective analysis Sleepwalking and sleep-eating are common parasomnias, also known as somnambulism and sleep-related eating disorder. Both can be side effects of benzos, z-hypnotics, and—rarely—antidepressants. This review looked at parasomnias’ association w

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

Clinical Update

Stimulants and Creativity

From The Carlat Psychiatry Report, Stopping Psych Meds Part 1

Your patient is a 25-year-old music teacher with ADHD. Though her organizational skills have improved with methylphenidate, she complains that it impairs her performance as a jazz musician: “I feel self-conscious, like a robot.” Popular lore holds that creative people have ADHD traits and that ADHD bestows advantages in creative thinking. Stock c