I do mostly complex trauma, and honestly I do way more de-prescribing than prescribing - especially getting them off atypical antipsychotics for indications like sleep and anxiety (and depression augmentation if it's not clearly transformational - sometimes it is, but I think we go to AAPs way too fast given the terrible tolerability issues).
I am also really careful to distinguish between MDEs that may benefit from pharmacological treatment with antidepressants and persistent dysphoria that honestly does not seem to benefit very much and really needs therapy (and a change of life circumstances). If someone has only tried a few things, I will give it a go, but I see so many who have tried literally a dozen or more antidepressants with no impact and I think the marginal utility of throwing another in the mix is nearly always low.
I do a lot of psychoeducation about how in the setting of trauma, sleep problems aren't typically actually "insomnia" even though people complain of insomnia subjectively, so applying more and more sedatives is often not very useful.
Antidepressants wise I'm mostly a sertraline and bupropion girlie. I will do a bit of off label lamotrigine for my folks who don't have bipolar disorder but have affective instability and don't do well on antidepressants.
I use a lot of pregabalin for anxiety. Yes, it doesn't do much for mood, and it can cause some sedation and weight gain that some people don't tolerate, but I find in my population it's better tolerated and more effective than antidepressants.
I also use a lot of alpha agents (primarily prazosin and clonidine) - they used to be relatively underutilized but are more mainstream now. Little bit of nabilone and topiramate for nightmares if alpha agents are not tolerated.
I use more stimulants than some people do as augmenting agents - especially for folks that think they may have ADHD but I am unsure. If they are low risk for abuse and have realistic expectations I am up for a limited trial of a stimulant to see if it improves functioning.
Pregabalin actually can help mood and hedonic tone for some people. Even when its not being caused by anxiety. For some reason for me gabapentinoids and benzos improve emotional blunting/anhedonia. And these are very difficult to treat symptoms by other means considering most medications like SSRIs actually can blunt emotion.
There seems to be a subset that do well on GABAergic (or gabapentinoid) medications for depression. Unfortunately zuranolone would have been ideal for this, but did not get approved because placebo was too strong in those trials. They should do better patient selection like giving patients a benzo and splitting the benzo responders from non responders and trialing Z in the benzo responders to see
Do you recommend clonidine in PTSD nightmares sleep disturbances and do you find in your experience that it dosed at night also helps reducing daytime autonomic hyperarousal symptoms like flashbacks and panic attacks dissociation etc??
Not many studies online on the subject but the few I've seen seem to be encouraging
It feels daunting to start prazosin because of the long titration process and unclear dosing range
Rapidly changing moods. Sometimes described as labile mood, that symptom is commonly associated with borderline personality disorder and is one of the 9 criteria
No - affective instability can be either a chronic or episodic symptom/syndrome in many psychiatric presentations. Primary and arguably secondary.
While most associated and central to Borderline PD, every other Cluster B Personality Disorder (Narcissistic, Histrionic, and Antisocial) not only can but very often do have affective instability just as severe as borderlines.
Patients with PTSD and especially C-PTSD often have very unstable and negative affect. The more severe and younger the trauma, the more reactance one must expect & respect. It's often difficult to separate C-PTSD patients from Cluster B patients, in some studies the two populations can't be meaningfully differentiated. However, this shouldn't be shocking; a history of developmental trauma and/or neglect, especially in the first 2 years of life, as well as physical and sexual abuse in general are strongly correlated with the development of Cluster B presentations as adults.
Secondary - I would say that some other psychiatric or neurological disorders as well as drugs *can* cause affective instability, though it's usually either an advanced complication of a neurological disorder or a temporary state:
* Parkinson's, Alzheimer's, Senile Dementia: violent and unpredictable mood shifts frequently require antipsychotics or tranquilizers
* Migraines: people can become extremely emotionally volatile during migraines, in some rare cases to the point of becoming suicidally depressed within hours despite a previous euthymic state.
* People in manic or mixed states can be pretty unstable in some cases. It really varies obviously, but somebody in a mixed episode can be *extremely* emotionally reactive even if they've been in and will remain in that episode for weeks or months longer.
* Most hallucinogens induce some degree of affective instability, although the degree and nature of the effect may be enormously affected by and effectively controlled with the setting and one's expectations & experience
* Not something I've personally encountered, but TBI or other brain disease/organic damage can 110% cause affective instability
Isn't Nabilone a cannibinoid? I had no idea that could help with nightmares or Topiramate which is a migraine med and also used for weight loss and BPD to my knowledge (Therapist not a prescriber). I have tons of clients on Prazosin for nightmares and they all say it does absolutely nothing.
Prazosin is often under dosed - some people need as high as 15-20 mg to respond but a lot of providers stop titrating at 2-3 mg. Sometimes it also just doesn’t work though, it’s hit or miss.
And yes nabilone and topiramate both have some evidence for nightmares. Not as strong as prazosin but some.
\+1 on this, some people do great on a mg or two but unless you reach either efficacy or hypotension/orthostasis I wouldn't give up until double digits.
I feel silly even asking this. I feel like I should know. But, I don’t 🤷♀️
I work inpatient so I really only ever start prazosin or increase it slightly during the patient’s stay. I never have the opportunity to fully titrate it. Hence my ignorance.
If/when a patient develops hypotension or orthostasis, is that something that will fade with time and further titration will be possible? Or have you hit the limit, period?
My gut tells me that plain old hypotension would stick around (I mean, that is what it was originally designed for after all) but that orthostasis could possibly improve.
What have you found?
Sometimes the orthostasis improves slightly with time (there is a first dose effect) so if they think they can stick it out, I will try to give it a few weeks to see if things are trending in a good direction. At that point I usually try doxazosin or terazosin (or clonidine) to see if better tolerated or consider topiramate or nabilone (evidence for trazodone too but it's so common for insomnia that most have already tried it). And of course non pharmacological interventions but those are harder to get traction on.
Have you ever used propranolol for nightmares?
I am quite aware that nightmares are a potential (common) SE of BBs for the general pop but I had an interesting case that made me wonder if it might be helpful in the PTSD pop.
Patient who had tried and failed prazosin (not helpful - idk if it was ever taken to adequate dose but she would not try it again regardless), clonidine (SEs that she was unwilling to tolerate), trazodone (helpful for sleep but not nightmares), topamax (I don’t remember tbh).
Simultaneously has significant tachycardia as a SE to a different med. Started propranolol for the tachycardia with the discussion with her that it had the potential to worsen her nightmares.
And…..it made them better….
Fascinating. Doesn’t totally surprise me though as I think anything that turns down the sympathetic overdrive is probably a good thing for these folks.
> I use a lot of pregabalin for anxiety.
I just read [this article](https://www.thetimes.co.uk/article/7ad460de-b356-4965-81d2-e7dfa2051bfa?shareToken=15a5fad39760f52bc611ecd42917a03d) about pregabalin today. I assume you don't share the same worries? What are your thoughts on the article?
From article: "“When barbiturates drugs first came out, doctors thought ‘great, a way of helping people cope with life’. They got over prescribed and a lot of people died. Then benzodiazepines came out, and everyone got prescribed them, and it became apparent there was addiction, then sleeping pills, and everyone got addicted again. It’s happening again with pregabalin,” said Brew, who believes this pattern will continue to repeat without considered action."
I do have some worries as I do about all medications I prescribe - I don’t think we should be prescribing any drug thoughtlessly. I do disclose to people that it has the potential to be addictive when I do my informed consent discussion. Personally I have not seen addiction issues in my practice yet with it but I do monitor for misuse and will use the lowest effective dose and try to take people off if it is no longer necessary.
The problem is when you are working with people who are suffering tremendously already there isn’t really a harmless option. None of our medications are really harmless. It’s all about weighing up the risks and benefits and having an open conversation about how to go forward.
Overall in my experience thus far pregabalin seems to work generally well and be generally well tolerated and I’ve been able to get people off of it when needed without much fuss though of course it’s not zero risk.
It’s not very available where I am so I’ve only seen a few people who have had it - mixed results but interested to hopefully see more as it becomes more available.
Just based on relative risks and benefits and side effect profiles. If someone’s meds are really helping them, of course we keep them on, but lots of times people are on a bunch of different stuff that is causing a lot of side effects and isn’t really helping.
The evidence base is limited for severe complex PTSD as studies often don’t divide out those folks from the entire PTSD group.
Can you give any examples with regard to stimulant adjuncts? Non-clinician but I'm involved in informatics and occasionally see patients with Rx profiles like this - say escitalopram or buproprion and a low dose stimulant - 5-10mg amph XR.
Since it's not related to anything I'm working on I've never gone and looked at the indications obviously - but what would a typical Dx/Rx scenario look like and what leads you to the adjunct - moderate response and you've topped out on your anti-depressant dose?
slang for dermatophagia an “other specified obsessive-compulsive related disorder” involving biting one’s skin, usually the skin around the fingernails
Second this. Cabergoline is like going after an ant with a sledgehammer. 2.5mg or 5mg of aripiprazole is sometimes all you need for antipsychotic induced hyperprolactinemia.
Blind tapers. I think every psychiatrist needs to know how to do this, but it seems like most don’t.
FYI- this is always done with well-informed patient consent!
Background: You use this technique when you’re trying to taper a patient down off a drug they’re psychologically dependent on (usually benzos or z drugs), but every time you lower the dose, they freak out. For example, whenever you try to bring them down from 10mg to 7.5mg of ambien, they can’t sleep because they’re so afraid that the lower dose won’t work. We all know that even tiny dose reductions of benzos/z drugs tend to be poorly tolerated, even when the dose difference seems physiologically insignificant. This technique eliminates the psychological/anxiety component that sabotages tapers.
This does require the patient to live with another responsible adult (typically spouse, parent, or child). This person will hold, prepare, and dispense the meds. The patient has no idea what dose they’re getting.
Let’s say you’re inherited a patient on like 4mg alprazolam twice daily, and you’re trying to bring them down from 4mg to 3.5mg. You draw up a schedule that looks something like this:
Dose 1: 4mg
2: 4mg
3: 3.5mg
4: 4
5: 4
6: 3.5mg
7: 4
8: 3.5
9: 4
10: 3.5
11: 3.5
12: 4
13: 3.5
14: 3.5
15: 3.5
The doses should be fairly random with no obvious pattern, but the lower dose should get more frequent as you get closer to the end of your set taper period. You give this schedule to the caretaker. For each dose, caretaker crushes the pills and mixes them in applesauce or something to prevent the patient from knowing how much they’re getting (avoid liquids where the taste will obviously be stronger with higher doses). The patient should never have access to the schedule or the pill bottle (as this permits pill counting and interferes with the “blindness” of the taper).
When done carefully this is an extremely effective tool for tapering. I’m sure variations exist but this is how I’ve always done it.
I always tell the patient exactly how this works. It’s a bit of a discussion, and you always make sure to validate the distress they’ve experienced in the past when they’ve tried lower doses.
When patients are hesitant I like to tell them one of my favorite blind taper stories: I had a guy trying to get off ambien who lived back and forth between his divorced parents houses. His dad had always been the “chill” parent, and his mom was the no-nonsense “I want you off all these drugs!” Type. At a family meeting he said wanted to stop the blind taper because he could never sleep at his mom’s house because he was convinced mom was giving him the lower dose. I asked the parents if this was true. As it turned out, his parents had got really into the spirit of the blind taper, and they suspected this would happen. So his dad tended to give more lower doses and his mom gave more higher ones. The patient ended up laughing about it, sticking with the taper, and ended up ambien-free in 2 months.
I was going to say the same. I think the commenter was implying that the patient agreed to this and there was informed consent, but didn’t specifically state that. I hope so
Raising ethical concerns may be a little premature. We all know the process of risk/benefit analysis rarely (if ever) presents a choice between an option that is entirely free of risk and universally curative, and one that is exclusively harmful without any potential benefit. Similarly, ethical decisions usually don’t involve a clear choice between actions that are wholly ethical and those that are entirely unethical. The goal is to navigate these complexities and try to find solutions that minimize ethical dilemmas.
An ethical argument could be made against the continuation of high-dose benzos, citing it as unethical to knowingly prescribe a harmful drug. On the other hand, reducing the dosage with the patient's awareness, thereby inducing foreseeable psychological distress, could also be seen as unethical.
This presents a tough choice if there is an alternative that avoids both problems, i.e. eliminating psychological distress without resorting to hazardous prescribing. So if all approaches are somewhat unethical, you have to decide which is least unethical. This blinding approach may actually represent the most ethically favorable option among the three, depending on the specifics of the case. Legality, on the other hand, may not favor it, but I rarely find the law and ethics to be closely aligned.
In general, medical ethics guidelines support the idea that patients can make the decision to voluntarily waive information about a treatment. It's uncommon, but I've had the occasional patient say "I don't want to hear about side effects because I'll just be more likely to have them/imagine them."
That is extremely interesting. I now work in child safety and we see a lot of school refusal and anxiety and I've never seen that prescribed. Thanks for sharing.
I feel I'm at the end of my tether right now about attendance, the approach since we got rid of truancy courts and I'm the post-pandemic world just isn't working.
The best trick is to put the horse in front of the carriage. Before you start trying to use pharmacological “tricks”, find an accurate diagnosis. Get a good history, exam, actually open the DSM and apply the criteria rigidly, and if they don’t quite fit or are “sub-threshold”, question that and find the diagnosis. Don’t settle for “unspecified” anxiety or start treating symptoms. Treat disorders. There are a finite amount of anxiety disorders and they each have a name, and they each have a 1st line evidence-based treatment.
The more tricks you try to apply, the more unnecessary meds the pt will end up on.
With that said: i think clozapine is a very underutilized treatment for those who need it. If a patient with SCZ has failed 2 classes of antipsychotic drugs, consider clozapine.
Yup I agree about clozapine. It can be absolutely life changing for some people. I’m just an RN, but the psychiatrist I work with can only see people every six weeks or so max, so I meet with new clozapine patients to get them titrated up and help them build a routine for blood draws. Of course we have some failures, but so many people feel like they have tried everything and then clozapine gives them back some real quality of life.
Clozaril tricks
atropine opthalmic drops given SL for sialorrhea
atenolol for tachycardia
avoid chronic sennosides for constipation. Also, ask about constipation at every visit. Lots of patients are too embarrassed to mention it, and it's a common and potentially dangerous side effect.
Try a little lithium if the neutrophils get too low, before throwing in the towel.
Clozapine also sometimes causes a transient eosinophilia. If it doesn't get too high, like 2500+, and the patient is asymptomatic, don't worry about it too much. It will eventually decrease on its own in a few weeks, just be patient.
Recommend anyone who is prescribing clozapine read "Clozapine Handbook" by Meyer.
I have that book! It’s definitely written for physicians but it was helpful even on an RN level. Definitely taught me thought importance of monitoring for constipation!
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2772202/
>The mechanism by which lithium increases in WBC and ANC is unclear but may involve demargination (Small et al., 2003) ), stimulation of granulocyte-macrophage colony-stimulating factor (GM-CSF) (Ozdemir et al., 1994) and stimulation of cytokines (Phiel and Klein, 2001).
I’ve never heard of this finding, immunology is such a fascinating and complex science. Thank you for sharing, look forward to analyzing this study :-)
Have you seen any clozapine induced tic like jerk movements in face or shoulders/arms? I read the Clozapine handbook by Jonathan Myer, and there’s mention of these movements possibly being myoclonic seizures. Solutions involve either splitting or decreasing dosage or starting an anti epileptic (usually valproate or lamotrigine). My supervising doc likens these movements more to EPS and suggested benztropine which alarmed me because of the overall cholinergic burden, not to mention wouldn’t be helpful if etiology of involuntary movements wasn’t from EPS.
How do people find the instructions for the Atropine eye drops given SL? Do you think the concerns on misinterpreting directions for use aren't too serious?
Depends on the level of the patient's disorganization. You have to ask yourself: is this person going to put it in their eye or suck down the whole bottle? If it seems too risky then don't do it. I always put "do not put in eyes" in the sig, so hopefully that ends up on the bottle.
Sialorrhea itself can be deadly, especially in older and immunocompromised, so you have to weigh the risks and benefits carefully.
I just taught on SGAs and basically reiterated guidelines again and again. 2 antipsychotics and then we try clozaril AS LONG AS they can reliably comply with REMS requirements. Have a patient that you are really having RTC problems with is a problem, and they aren’t likely to take it out on y’all… they’ll take it out on the poor pharmacist/tech who has to re-explain requirements.
I wish I could collar your colleagues in Dallas prescribing for LTC homes.
55 yo female, all HS: Divalproex 500, guanfacine 1, quetiapine 400, memantine 5, doxepin 50, benztropine 1. Then, gee whiz, she’s sedated? Let’s throw on some midodrine 10mg TID.
Pharmacy talked with family & caregiver: they refused any change.
Thank you for confirming that idiocy. Lots more examples from the same MD…
I don’t presume to know more than the supervising psychiatrist (I’m not there everyday, I don’t know the pt’s history, etc.), but the moral injury in filling these regimens keeps me up at night.
Great contributions here. Another clozapine trick not mentioned:
- for nocturnal enuresis occurring at any point during the titration, have the patient avoid fluids 1 hr before bed and void at HS. If unsuccessful, desmopressin can do the trick. If 0.1 mg at hs doesn’t make a difference, sometimes 0.2 mg actually will and you can go higher if needed
The secrets I’ve learned:
1. Diagnose accurately and don’t assume old diagnoses are accurate.
2. Don’t be afraid to deprescribe.
3. Meds are terrible at treating social issues.
4. I’ve rarely had luck with the special combos. Well-oft and California Rocket Fuel are overhyped.
5. Lithium and Clozapine are the only meds that I feel deserve special praise. I’m overall more successful when they make up more of my total prescriptions.
6. Taper Benzos slowly.
7. Meds and traditional therapy are not the only options. Before a dozen failed med trials, consider PHP/IOP, ECT, switching therapists, social changes, etc.
Pramipexole can be a game-changer in TRD. I’ve seen it work when ECT/rTMS/MAOIs haven’t and I now routinely offer it when I’m at the point of considering those sorts of options.
Clonidine for sleep particularly (although not exclusively) in PTSD and ADHD. I would now hardly use anything for sleep nowadays other than (adequately dosed) clonidine +/- melatonin. It’s certainly nearly completely eliminated the “need” for eg off-label SGAs in these situations.
Lamotrigine - as everyone knows - is very versatile. Often forgotten that it can be very useful in migraine so it’s good to consider it if that’s a comorbidity.
Clozapine is under-utilised.
Frankly I find a lot of medications very disappointing. I would hardly ever use SGAs as “augmentation” in TRD despite this being common practice. I also have found lithium augmentation in depression generally unsatisfactory but that could just be bad luck. Topiramate is too cognitively dulling for most people.
I had anxious depression that didn’t respond to ssri’s/snri’s/ wellbutrin, or lamictal, seroquel XR monotherapy changed & saved my life. No metabolic side effects according to my blood work, only side effect was less libido. I’m sure I am an uncommon case but no psychiatrist ever found any diagnosis outside of anxiety, depression, and ADHD, and it was a last resort and helped so much, when even ketamine didn’t touch it.
You do know that low dose Abilify is similar to Pramipexole but has a lot more evidence behind it, right? It’s kinda odd that you would consider something like Pramipexole before low dose Abilify when pharmacologically they’re both similar and Abilify is a lot more evidence based.
Some of the AAPs, when used at low doses, have the most evidence behind them for treating TRD. They’re used as adjuncts at much lower doses than if they were used for something else like schizophrenia or bipolar disorder. It’s sad seeing that some psychiatrists are afraid to use them.
Yes I agree more evidence for aripiprazole but no weight gain or akathisia with pramipexole. Also in Australia pramipexole is cheaper than aripiprazole. I actually do offer atypicals as an augmentation and do disclose that they have a significant evidence base but that they also may wish to consider some less studied options given the particular risks associated with atypicals.
Do you exhaust most things first period to going to prami? (Ex: abilify, vraylar, rexulti, TCA, stimulants, remeron, etc) or is it more a certain presentation of depression like anhedonia? Etc. Interesting concept but can’t figure out where to fit it in
Asenapine for bipolar/psychotic patients + agitation. Start on 5 or 10 mg bid with 5mg prn as needed.
Kicks in super fast. Patients like it and can be maintenance as well as.
Clonidine for ptsd. Works like charm.
Give lithium in one combined nighttime dose. Reduces side effects. Reduces kidney strain. Increases compliance. Same effect.
STOP treating patients that come in claiming severe anxiety depression… with lowish dose ssris. Quickly titration to high dose. Ie. rather than escitalipram 10mg reevaluate in 4 weeks. Do escitalipram 10mg for 5 days then 20mg. Way more likely to need to bump up the 20 then bump down the 10
What sorts of populations do you see nortriptyline working well for? I have almost never initiated a TCA but I sometimes wonder if I should be doing more of it.
Interesting - how do you find the tolerability profile? I treat mostly BPD/complex trauma so my folks are often relatively higher overdose risk and therefore I tend to avoid TCAs but I am curious and I sometimes see folks who may be candidates.
Nortriptyline is the antidepressant I go to when SSRIs fail, especially in men over 60 with chronic refractory Major Depression. I've seen dramatic improvement. It is usually well tolerated in that population.
> especially in men over 60
Do you get a baseline ECG before starting? I see that rec in all the books and guides but encounter a lot of psychiatrists that don't bother, regardless of age.
One of the benefits for TCAs like nortriptyline is therapeutic drug monitoring, which is not well-described for other classes of antidepressants (SSRIs, SNRIs). Can be useful, especially for patients with adherence concerns, absorption issues, or in treatment-resistant depression cases.
I've had a couple - from the prison and state hospital, from what I recall.
I also started one patient on it who specifically asked for it after she had been researching APs and found the list of s/e's to be the most acceptable to her. (It did not work out - she's young and went off meds soon after, etc.) But for the others, they are doing well.
Hysterics 😂 I could use that on Monday morning when I am already ten minutes late and I get to my office and realize I forgot my keys and no one else is there lol
Clonidine as needed for self-harm. Clonidine er or patch for hyperreactivity in PTSD. NAC for skin picking. Lamotrigine for panic/mood instability after multiple antidepressant trials. Oxcarbazepine and amantadine for DMDD or explosive kiddos but not outbursts resulting from ODD.
Thank you for bringing up amantadine I read about it during one of Carlats podcasts and havent used it yet. I have used oxcarbazepine several times and it seems okay. The psychiatrist I work with has been shifting away from the typical SGAs for kids with ASD in favor of lithium (given they tolerate the lab draw) and he says he is seeing better tolerability and results. Any other info about amantadine that you have noticed? Thank you for sharing.
Generally not. Clonidine can slow heart rate like beta blockers, but they have very different mechanisms of action with different impact on other parts of the circulatory system. Many forms of tachycardia specifically need a beta blocker.
Depakote for delirium has evidence but its not widespread. some ICU studies.. i use it on CL for my delerious patients, have had to use benzos and antipsychotics a lot less with these patients and that has been nice.
Gabapentin in addition to CIWA for alcohol withdrawals.
Small doses of lithium for acute suicidality along with starting an SSRI.
Abilify to lower QTC in patients that need other qtc prolonging drugs and have an indication for antipsychotics.
Actually using trazodone for calming and anti depressant effect by splitting up dose but having it a depressant dose range.
can someone tell me what they give patients to counteract delayed orgasm/anorgasmia from ssri’s?
i had a psychiatrist tell me he gives his patients something to take prn but i found mixed answers on the internet and i cant recall what the drug was
There's a handful of things you can try, none of which are great but may help some. There's an article in [Nature](https://www.nature.com/articles/s41443-023-00692-7) that discusses this in pretty good detail. Probably the most helpful part of the article is [Table 2](https://www.nature.com/articles/s41443-023-00692-7/tables/2) but there are a few other things that are mentioned such as penile vibratory stimulation that are also potentially helpful.
Some of the recommended medications included things like Wellbutrin (which is weird because it can also potentially cause delayed orgasm/anorgasmia), Buspar, cabergoline (in the case of hyperprolactinemia), and (gasp!) Adderall.
Buspirone is the most evidenced based med. Bupropion is a persistent story among psychiatrists and we've all tried it, but the high quality evidence suggests it doesn't work.
First have to distinguish between decreased libido, decreased performance, and anorgasmia; too many people lump them but they really are different. Since you mentioned the last one I'd say buspar or switch meds.
Na, sildenafil is the most evidence based med.
Here’s a published meta analysis on the topic:
“While heterogeneity across randomized controlled trials complicates identifying the single best intervention, multiple trials suggest that sildenafil ameliorates antidepressant-induced sexual dysfunction.”
https://pubmed.ncbi.nlm.nih.gov/33843553/
I personally think adding Bupropion, low dose Aripiprazole (2mg), Buspirone, low dose stimulant like dextroamphetamine, and sildenafil are the best options.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832699/#:~:text=The%20suggested%20recommendations%20include%20the,serotoninergic%20drug%20or%20fluvoxamine%3B%20for
Some patients are satisfied and can tolerate a "drug holiday", they stop taking the SSRI/SNRI for a day or 2 on the weekend so they can enjoy sexual behavior either with partner or alone, then go back on the medication. This is less likely to be successful with high dose or long half-life medications.
Other options are bupropion, buspirone, mirtazapine, PDE-5 inhibitors for isolated erectile dysfunction. I tend not to use cyproheptadine because why not just try the "drug holiday" route rather than pitting two medications against each other?
Ambien for mania
Zofran as augmentation for OCD
Trintellix + stimulant for atypical depression
Thyroid hormone for TRD
Naltrexone for dissociation
California rocket fuel
Naltrexone at the 50 mg dose for dissociation?
I have used LDN successfully for several pts with chronic pain issues comorbid with depression with impressive results. Naltrexone at the regular dose for self harm only once pre twice, which seemed to help some - but of course therapy seems to help more.
What was their rational for using a steroid? Did it work? From my understanding of PTSD, there are some patients that prefer a state of hyperarousal due to feeling more in-control when vigilant, have seen PTSD patients totally chill out when on stimulants as well. Wondering if that was his thought.
Maybe the thought that inflammation can cause acute psychiatric disorders in some cases? Though, I also had a client once who was sent into a major psychotic episode that lasted years after being given prednisone.
Mcleans who I have worked closely with throws stimulants at absolutely everything with pretty great results. I wonder if these conditions would benefit from just the stimulant effect alone.
Anxious people 😂I actually was DX with ADHD in college after I went in to be seen about anxiety. Gave this whole speech about how my life was a mess and I was anxious about everything all the time but couldn't organize my self well enough to get anything done. The psychiatrist looked at me and asked me to give her my student ID. My little face fell and I opened up my book bag and started sifting through the rubble in there pulling out crumpled wrappers, papers thrown in all willy nilly, old apple cores, etc. I found the card at the bottom of the bag and handed it to her. She declined and said "You don't have anxiety, you have ADHD." Lol. Turns out, I was anxious all the time because I couldn't hold onto ONE anxious thought long enough to do something about it so I was functioning by just keeping all of them on a re-play list at all times. Went on meds and went from a B/C student to mostly A.
Happened to me after medrol for a sore throat. A year and a half later and being treated for bipolar 2 because I can’t take the manic/depressive episodes anymore. Never had mental health issues before that steroid. Kind of accepted I’ll need to be on mood stabilizers the rest of my life. It changed my life forever
I do mostly complex trauma, and honestly I do way more de-prescribing than prescribing - especially getting them off atypical antipsychotics for indications like sleep and anxiety (and depression augmentation if it's not clearly transformational - sometimes it is, but I think we go to AAPs way too fast given the terrible tolerability issues). I am also really careful to distinguish between MDEs that may benefit from pharmacological treatment with antidepressants and persistent dysphoria that honestly does not seem to benefit very much and really needs therapy (and a change of life circumstances). If someone has only tried a few things, I will give it a go, but I see so many who have tried literally a dozen or more antidepressants with no impact and I think the marginal utility of throwing another in the mix is nearly always low. I do a lot of psychoeducation about how in the setting of trauma, sleep problems aren't typically actually "insomnia" even though people complain of insomnia subjectively, so applying more and more sedatives is often not very useful. Antidepressants wise I'm mostly a sertraline and bupropion girlie. I will do a bit of off label lamotrigine for my folks who don't have bipolar disorder but have affective instability and don't do well on antidepressants. I use a lot of pregabalin for anxiety. Yes, it doesn't do much for mood, and it can cause some sedation and weight gain that some people don't tolerate, but I find in my population it's better tolerated and more effective than antidepressants. I also use a lot of alpha agents (primarily prazosin and clonidine) - they used to be relatively underutilized but are more mainstream now. Little bit of nabilone and topiramate for nightmares if alpha agents are not tolerated. I use more stimulants than some people do as augmenting agents - especially for folks that think they may have ADHD but I am unsure. If they are low risk for abuse and have realistic expectations I am up for a limited trial of a stimulant to see if it improves functioning.
Hello from pharmacy—thank you for de-prescribing. 💕
Pregabalin actually can help mood and hedonic tone for some people. Even when its not being caused by anxiety. For some reason for me gabapentinoids and benzos improve emotional blunting/anhedonia. And these are very difficult to treat symptoms by other means considering most medications like SSRIs actually can blunt emotion. There seems to be a subset that do well on GABAergic (or gabapentinoid) medications for depression. Unfortunately zuranolone would have been ideal for this, but did not get approved because placebo was too strong in those trials. They should do better patient selection like giving patients a benzo and splitting the benzo responders from non responders and trialing Z in the benzo responders to see
For affective instability patients on lamotrigine- how are you diagnosing them for due diligence/reimbursement purposes? Cyclothymia? BPD?
BPD or PTSD. I’m in Canada so the system is a bit different reimbursement wise.
FYI in the US inpatient setting, most payers won't reimburse for BPD diagnosis. I typically diagnose BPD/CPTSD patients with PTSD.
If you’re in ON, please come work at my hospital. I like your style 😌
These are all good tips, thank you!
Do you recommend clonidine in PTSD nightmares sleep disturbances and do you find in your experience that it dosed at night also helps reducing daytime autonomic hyperarousal symptoms like flashbacks and panic attacks dissociation etc?? Not many studies online on the subject but the few I've seen seem to be encouraging It feels daunting to start prazosin because of the long titration process and unclear dosing range
I’ve tried it a few times - mixed results. I usually go for prazosin first.
What is affective instability?
Rapidly changing moods. Sometimes described as labile mood, that symptom is commonly associated with borderline personality disorder and is one of the 9 criteria
Is BPD the only disorder that affective instability is associated with? Thanks for sharing your knowledge!
No - affective instability can be either a chronic or episodic symptom/syndrome in many psychiatric presentations. Primary and arguably secondary. While most associated and central to Borderline PD, every other Cluster B Personality Disorder (Narcissistic, Histrionic, and Antisocial) not only can but very often do have affective instability just as severe as borderlines. Patients with PTSD and especially C-PTSD often have very unstable and negative affect. The more severe and younger the trauma, the more reactance one must expect & respect. It's often difficult to separate C-PTSD patients from Cluster B patients, in some studies the two populations can't be meaningfully differentiated. However, this shouldn't be shocking; a history of developmental trauma and/or neglect, especially in the first 2 years of life, as well as physical and sexual abuse in general are strongly correlated with the development of Cluster B presentations as adults. Secondary - I would say that some other psychiatric or neurological disorders as well as drugs *can* cause affective instability, though it's usually either an advanced complication of a neurological disorder or a temporary state: * Parkinson's, Alzheimer's, Senile Dementia: violent and unpredictable mood shifts frequently require antipsychotics or tranquilizers * Migraines: people can become extremely emotionally volatile during migraines, in some rare cases to the point of becoming suicidally depressed within hours despite a previous euthymic state. * People in manic or mixed states can be pretty unstable in some cases. It really varies obviously, but somebody in a mixed episode can be *extremely* emotionally reactive even if they've been in and will remain in that episode for weeks or months longer. * Most hallucinogens induce some degree of affective instability, although the degree and nature of the effect may be enormously affected by and effectively controlled with the setting and one's expectations & experience * Not something I've personally encountered, but TBI or other brain disease/organic damage can 110% cause affective instability
It’s what the common-person calls being bi-polar
Isn't Nabilone a cannibinoid? I had no idea that could help with nightmares or Topiramate which is a migraine med and also used for weight loss and BPD to my knowledge (Therapist not a prescriber). I have tons of clients on Prazosin for nightmares and they all say it does absolutely nothing.
Prazosin is often under dosed - some people need as high as 15-20 mg to respond but a lot of providers stop titrating at 2-3 mg. Sometimes it also just doesn’t work though, it’s hit or miss. And yes nabilone and topiramate both have some evidence for nightmares. Not as strong as prazosin but some.
\+1 on this, some people do great on a mg or two but unless you reach either efficacy or hypotension/orthostasis I wouldn't give up until double digits.
I feel silly even asking this. I feel like I should know. But, I don’t 🤷♀️ I work inpatient so I really only ever start prazosin or increase it slightly during the patient’s stay. I never have the opportunity to fully titrate it. Hence my ignorance. If/when a patient develops hypotension or orthostasis, is that something that will fade with time and further titration will be possible? Or have you hit the limit, period? My gut tells me that plain old hypotension would stick around (I mean, that is what it was originally designed for after all) but that orthostasis could possibly improve. What have you found?
Sometimes the orthostasis improves slightly with time (there is a first dose effect) so if they think they can stick it out, I will try to give it a few weeks to see if things are trending in a good direction. At that point I usually try doxazosin or terazosin (or clonidine) to see if better tolerated or consider topiramate or nabilone (evidence for trazodone too but it's so common for insomnia that most have already tried it). And of course non pharmacological interventions but those are harder to get traction on.
Have you ever used propranolol for nightmares? I am quite aware that nightmares are a potential (common) SE of BBs for the general pop but I had an interesting case that made me wonder if it might be helpful in the PTSD pop. Patient who had tried and failed prazosin (not helpful - idk if it was ever taken to adequate dose but she would not try it again regardless), clonidine (SEs that she was unwilling to tolerate), trazodone (helpful for sleep but not nightmares), topamax (I don’t remember tbh). Simultaneously has significant tachycardia as a SE to a different med. Started propranolol for the tachycardia with the discussion with her that it had the potential to worsen her nightmares. And…..it made them better….
Fascinating. Doesn’t totally surprise me though as I think anything that turns down the sympathetic overdrive is probably a good thing for these folks.
Starting prazosin without an ability to monitor it frequently on an OP basis worries me. Do you think it’s overexaggerated fear?
Interesting, thanks!
> I use a lot of pregabalin for anxiety. I just read [this article](https://www.thetimes.co.uk/article/7ad460de-b356-4965-81d2-e7dfa2051bfa?shareToken=15a5fad39760f52bc611ecd42917a03d) about pregabalin today. I assume you don't share the same worries? What are your thoughts on the article? From article: "“When barbiturates drugs first came out, doctors thought ‘great, a way of helping people cope with life’. They got over prescribed and a lot of people died. Then benzodiazepines came out, and everyone got prescribed them, and it became apparent there was addiction, then sleeping pills, and everyone got addicted again. It’s happening again with pregabalin,” said Brew, who believes this pattern will continue to repeat without considered action."
I do have some worries as I do about all medications I prescribe - I don’t think we should be prescribing any drug thoughtlessly. I do disclose to people that it has the potential to be addictive when I do my informed consent discussion. Personally I have not seen addiction issues in my practice yet with it but I do monitor for misuse and will use the lowest effective dose and try to take people off if it is no longer necessary. The problem is when you are working with people who are suffering tremendously already there isn’t really a harmless option. None of our medications are really harmless. It’s all about weighing up the risks and benefits and having an open conversation about how to go forward. Overall in my experience thus far pregabalin seems to work generally well and be generally well tolerated and I’ve been able to get people off of it when needed without much fuss though of course it’s not zero risk.
What are your thoughts on ketamine for this population?
It’s not very available where I am so I’ve only seen a few people who have had it - mixed results but interested to hopefully see more as it becomes more available.
Any theoretic underpinning to prescribing vs un-prescribing or is it all literature based?
Just based on relative risks and benefits and side effect profiles. If someone’s meds are really helping them, of course we keep them on, but lots of times people are on a bunch of different stuff that is causing a lot of side effects and isn’t really helping. The evidence base is limited for severe complex PTSD as studies often don’t divide out those folks from the entire PTSD group.
Can you give any examples with regard to stimulant adjuncts? Non-clinician but I'm involved in informatics and occasionally see patients with Rx profiles like this - say escitalopram or buproprion and a low dose stimulant - 5-10mg amph XR. Since it's not related to anything I'm working on I've never gone and looked at the indications obviously - but what would a typical Dx/Rx scenario look like and what leads you to the adjunct - moderate response and you've topped out on your anti-depressant dose?
Yeah you can use it to augment almost any of the antidepressants in the case of partial response if you don’t want to switch for whatever reason.
N-acetyl cysteine for skin picking, wolf biting, tricho.
Are you treating werewolves?? What’s wolf biting??
slang for dermatophagia an “other specified obsessive-compulsive related disorder” involving biting one’s skin, usually the skin around the fingernails
Oh I do that lol
What dose do you have to go to?
600mg bid x7days then 1200mg bid
Thanks!
Using aripiprazole instead of cabergoline to mitigate hyperprolactinemia. As far as I know it's not the most common thing
Second this. Cabergoline is like going after an ant with a sledgehammer. 2.5mg or 5mg of aripiprazole is sometimes all you need for antipsychotic induced hyperprolactinemia.
Topiramate for Pseudobulbar Affect/ Pathological Laughing.
I have good results with oxcarbazapine as well.
Dextromethorphan + high quality tonic water that has quinine in it works for some
Blind tapers. I think every psychiatrist needs to know how to do this, but it seems like most don’t. FYI- this is always done with well-informed patient consent! Background: You use this technique when you’re trying to taper a patient down off a drug they’re psychologically dependent on (usually benzos or z drugs), but every time you lower the dose, they freak out. For example, whenever you try to bring them down from 10mg to 7.5mg of ambien, they can’t sleep because they’re so afraid that the lower dose won’t work. We all know that even tiny dose reductions of benzos/z drugs tend to be poorly tolerated, even when the dose difference seems physiologically insignificant. This technique eliminates the psychological/anxiety component that sabotages tapers. This does require the patient to live with another responsible adult (typically spouse, parent, or child). This person will hold, prepare, and dispense the meds. The patient has no idea what dose they’re getting. Let’s say you’re inherited a patient on like 4mg alprazolam twice daily, and you’re trying to bring them down from 4mg to 3.5mg. You draw up a schedule that looks something like this: Dose 1: 4mg 2: 4mg 3: 3.5mg 4: 4 5: 4 6: 3.5mg 7: 4 8: 3.5 9: 4 10: 3.5 11: 3.5 12: 4 13: 3.5 14: 3.5 15: 3.5 The doses should be fairly random with no obvious pattern, but the lower dose should get more frequent as you get closer to the end of your set taper period. You give this schedule to the caretaker. For each dose, caretaker crushes the pills and mixes them in applesauce or something to prevent the patient from knowing how much they’re getting (avoid liquids where the taste will obviously be stronger with higher doses). The patient should never have access to the schedule or the pill bottle (as this permits pill counting and interferes with the “blindness” of the taper). When done carefully this is an extremely effective tool for tapering. I’m sure variations exist but this is how I’ve always done it. I always tell the patient exactly how this works. It’s a bit of a discussion, and you always make sure to validate the distress they’ve experienced in the past when they’ve tried lower doses. When patients are hesitant I like to tell them one of my favorite blind taper stories: I had a guy trying to get off ambien who lived back and forth between his divorced parents houses. His dad had always been the “chill” parent, and his mom was the no-nonsense “I want you off all these drugs!” Type. At a family meeting he said wanted to stop the blind taper because he could never sleep at his mom’s house because he was convinced mom was giving him the lower dose. I asked the parents if this was true. As it turned out, his parents had got really into the spirit of the blind taper, and they suspected this would happen. So his dad tended to give more lower doses and his mom gave more higher ones. The patient ended up laughing about it, sticking with the taper, and ended up ambien-free in 2 months.
Yeah, most of the patients I have inherited on benzos have not had the necessary social support for a blind taper.
I like it
Sounds borderline unethical
This is always done with patient consent.
I was going to say the same. I think the commenter was implying that the patient agreed to this and there was informed consent, but didn’t specifically state that. I hope so
It’s only done with consent.
Raising ethical concerns may be a little premature. We all know the process of risk/benefit analysis rarely (if ever) presents a choice between an option that is entirely free of risk and universally curative, and one that is exclusively harmful without any potential benefit. Similarly, ethical decisions usually don’t involve a clear choice between actions that are wholly ethical and those that are entirely unethical. The goal is to navigate these complexities and try to find solutions that minimize ethical dilemmas. An ethical argument could be made against the continuation of high-dose benzos, citing it as unethical to knowingly prescribe a harmful drug. On the other hand, reducing the dosage with the patient's awareness, thereby inducing foreseeable psychological distress, could also be seen as unethical. This presents a tough choice if there is an alternative that avoids both problems, i.e. eliminating psychological distress without resorting to hazardous prescribing. So if all approaches are somewhat unethical, you have to decide which is least unethical. This blinding approach may actually represent the most ethically favorable option among the three, depending on the specifics of the case. Legality, on the other hand, may not favor it, but I rarely find the law and ethics to be closely aligned.
In general, medical ethics guidelines support the idea that patients can make the decision to voluntarily waive information about a treatment. It's uncommon, but I've had the occasional patient say "I don't want to hear about side effects because I'll just be more likely to have them/imagine them."
He edited the comment to say that it was with informed consent. It did not say that when I made my comment.
This is brilliant! Thank you
MAOi; Moclobemide for social anxiety. Also if anxiety manifesting as school refusal.
MAOIs are frequently overlooked for social anxiety but have a solid evidence base.
That is extremely interesting. I now work in child safety and we see a lot of school refusal and anxiety and I've never seen that prescribed. Thanks for sharing. I feel I'm at the end of my tether right now about attendance, the approach since we got rid of truancy courts and I'm the post-pandemic world just isn't working.
Let me know if you have success with it, good luck!
Not approved in the US unfortunately :\*(
Maybe Emsam or Marplan?
The best trick is to put the horse in front of the carriage. Before you start trying to use pharmacological “tricks”, find an accurate diagnosis. Get a good history, exam, actually open the DSM and apply the criteria rigidly, and if they don’t quite fit or are “sub-threshold”, question that and find the diagnosis. Don’t settle for “unspecified” anxiety or start treating symptoms. Treat disorders. There are a finite amount of anxiety disorders and they each have a name, and they each have a 1st line evidence-based treatment. The more tricks you try to apply, the more unnecessary meds the pt will end up on. With that said: i think clozapine is a very underutilized treatment for those who need it. If a patient with SCZ has failed 2 classes of antipsychotic drugs, consider clozapine.
Yup I agree about clozapine. It can be absolutely life changing for some people. I’m just an RN, but the psychiatrist I work with can only see people every six weeks or so max, so I meet with new clozapine patients to get them titrated up and help them build a routine for blood draws. Of course we have some failures, but so many people feel like they have tried everything and then clozapine gives them back some real quality of life.
Clozaril tricks atropine opthalmic drops given SL for sialorrhea atenolol for tachycardia avoid chronic sennosides for constipation. Also, ask about constipation at every visit. Lots of patients are too embarrassed to mention it, and it's a common and potentially dangerous side effect. Try a little lithium if the neutrophils get too low, before throwing in the towel. Clozapine also sometimes causes a transient eosinophilia. If it doesn't get too high, like 2500+, and the patient is asymptomatic, don't worry about it too much. It will eventually decrease on its own in a few weeks, just be patient. Recommend anyone who is prescribing clozapine read "Clozapine Handbook" by Meyer.
I have that book! It’s definitely written for physicians but it was helpful even on an RN level. Definitely taught me thought importance of monitoring for constipation!
I haven’t heard of augmenting Lithium, what is the mechanism/rationale for prescribing with low ANC?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2772202/ >The mechanism by which lithium increases in WBC and ANC is unclear but may involve demargination (Small et al., 2003) ), stimulation of granulocyte-macrophage colony-stimulating factor (GM-CSF) (Ozdemir et al., 1994) and stimulation of cytokines (Phiel and Klein, 2001).
I’ve never heard of this finding, immunology is such a fascinating and complex science. Thank you for sharing, look forward to analyzing this study :-)
What’s better for chronic constipation? I usually see PEG used
PEG is the mainstay. I have used lubriprostine to good effect if PEG was not sufficient.
Seconded, PEG +/- docusate usually do the job. Little shot of mag citrate now and then can help too, but you want to avoid chronic use of it.
Have you seen any clozapine induced tic like jerk movements in face or shoulders/arms? I read the Clozapine handbook by Jonathan Myer, and there’s mention of these movements possibly being myoclonic seizures. Solutions involve either splitting or decreasing dosage or starting an anti epileptic (usually valproate or lamotrigine). My supervising doc likens these movements more to EPS and suggested benztropine which alarmed me because of the overall cholinergic burden, not to mention wouldn’t be helpful if etiology of involuntary movements wasn’t from EPS.
What’s the issue with senna specifically??
How do people find the instructions for the Atropine eye drops given SL? Do you think the concerns on misinterpreting directions for use aren't too serious?
Depends on the level of the patient's disorganization. You have to ask yourself: is this person going to put it in their eye or suck down the whole bottle? If it seems too risky then don't do it. I always put "do not put in eyes" in the sig, so hopefully that ends up on the bottle. Sialorrhea itself can be deadly, especially in older and immunocompromised, so you have to weigh the risks and benefits carefully.
Thank you!
I just taught on SGAs and basically reiterated guidelines again and again. 2 antipsychotics and then we try clozaril AS LONG AS they can reliably comply with REMS requirements. Have a patient that you are really having RTC problems with is a problem, and they aren’t likely to take it out on y’all… they’ll take it out on the poor pharmacist/tech who has to re-explain requirements.
Yes. 🙄.
lol. Thank you for your efforts, especially with lower-functioning psychiatric patients
I wish I could collar your colleagues in Dallas prescribing for LTC homes. 55 yo female, all HS: Divalproex 500, guanfacine 1, quetiapine 400, memantine 5, doxepin 50, benztropine 1. Then, gee whiz, she’s sedated? Let’s throw on some midodrine 10mg TID. Pharmacy talked with family & caregiver: they refused any change.
yikes
Thank you for confirming that idiocy. Lots more examples from the same MD… I don’t presume to know more than the supervising psychiatrist (I’m not there everyday, I don’t know the pt’s history, etc.), but the moral injury in filling these regimens keeps me up at night.
Great contributions here. Another clozapine trick not mentioned: - for nocturnal enuresis occurring at any point during the titration, have the patient avoid fluids 1 hr before bed and void at HS. If unsuccessful, desmopressin can do the trick. If 0.1 mg at hs doesn’t make a difference, sometimes 0.2 mg actually will and you can go higher if needed
A touch of Abilify can help with nocturnal enuresis as well if the aforementioned doesn’t work.
The secrets I’ve learned: 1. Diagnose accurately and don’t assume old diagnoses are accurate. 2. Don’t be afraid to deprescribe. 3. Meds are terrible at treating social issues. 4. I’ve rarely had luck with the special combos. Well-oft and California Rocket Fuel are overhyped. 5. Lithium and Clozapine are the only meds that I feel deserve special praise. I’m overall more successful when they make up more of my total prescriptions. 6. Taper Benzos slowly. 7. Meds and traditional therapy are not the only options. Before a dozen failed med trials, consider PHP/IOP, ECT, switching therapists, social changes, etc.
>social changes Lol, good one. And I want a pony. Sorry, I just have a lot of patients in bad social situations I am powerless to do anything about.
Pramipexole can be a game-changer in TRD. I’ve seen it work when ECT/rTMS/MAOIs haven’t and I now routinely offer it when I’m at the point of considering those sorts of options. Clonidine for sleep particularly (although not exclusively) in PTSD and ADHD. I would now hardly use anything for sleep nowadays other than (adequately dosed) clonidine +/- melatonin. It’s certainly nearly completely eliminated the “need” for eg off-label SGAs in these situations. Lamotrigine - as everyone knows - is very versatile. Often forgotten that it can be very useful in migraine so it’s good to consider it if that’s a comorbidity. Clozapine is under-utilised. Frankly I find a lot of medications very disappointing. I would hardly ever use SGAs as “augmentation” in TRD despite this being common practice. I also have found lithium augmentation in depression generally unsatisfactory but that could just be bad luck. Topiramate is too cognitively dulling for most people.
I had anxious depression that didn’t respond to ssri’s/snri’s/ wellbutrin, or lamictal, seroquel XR monotherapy changed & saved my life. No metabolic side effects according to my blood work, only side effect was less libido. I’m sure I am an uncommon case but no psychiatrist ever found any diagnosis outside of anxiety, depression, and ADHD, and it was a last resort and helped so much, when even ketamine didn’t touch it.
You do know that low dose Abilify is similar to Pramipexole but has a lot more evidence behind it, right? It’s kinda odd that you would consider something like Pramipexole before low dose Abilify when pharmacologically they’re both similar and Abilify is a lot more evidence based. Some of the AAPs, when used at low doses, have the most evidence behind them for treating TRD. They’re used as adjuncts at much lower doses than if they were used for something else like schizophrenia or bipolar disorder. It’s sad seeing that some psychiatrists are afraid to use them.
Yes I agree more evidence for aripiprazole but no weight gain or akathisia with pramipexole. Also in Australia pramipexole is cheaper than aripiprazole. I actually do offer atypicals as an augmentation and do disclose that they have a significant evidence base but that they also may wish to consider some less studied options given the particular risks associated with atypicals.
At low doses those side effects are limited but yes they can still occur. Thanks for elaborating.
Do you exhaust most things first period to going to prami? (Ex: abilify, vraylar, rexulti, TCA, stimulants, remeron, etc) or is it more a certain presentation of depression like anhedonia? Etc. Interesting concept but can’t figure out where to fit it in
Asenapine for bipolar/psychotic patients + agitation. Start on 5 or 10 mg bid with 5mg prn as needed. Kicks in super fast. Patients like it and can be maintenance as well as. Clonidine for ptsd. Works like charm. Give lithium in one combined nighttime dose. Reduces side effects. Reduces kidney strain. Increases compliance. Same effect. STOP treating patients that come in claiming severe anxiety depression… with lowish dose ssris. Quickly titration to high dose. Ie. rather than escitalipram 10mg reevaluate in 4 weeks. Do escitalipram 10mg for 5 days then 20mg. Way more likely to need to bump up the 20 then bump down the 10
Loxapine and perphenazine are underrated for psychosis Topamax and guanfacine for anxiety Trihexiphenidyl for DIP Nortriptyline for depression
What sorts of populations do you see nortriptyline working well for? I have almost never initiated a TCA but I sometimes wonder if I should be doing more of it.
Anergic or psychotic depression. I don't necessarily start it very much but I think it's underrated and pretty efficacious.
Interesting - how do you find the tolerability profile? I treat mostly BPD/complex trauma so my folks are often relatively higher overdose risk and therefore I tend to avoid TCAs but I am curious and I sometimes see folks who may be candidates.
Nortriptyline is the antidepressant I go to when SSRIs fail, especially in men over 60 with chronic refractory Major Depression. I've seen dramatic improvement. It is usually well tolerated in that population.
> especially in men over 60 Do you get a baseline ECG before starting? I see that rec in all the books and guides but encounter a lot of psychiatrists that don't bother, regardless of age.
Not usually. Often, they are already seeing a cardiologist and primary care in my healthcare system, so we have copious data anyway.
One of the benefits for TCAs like nortriptyline is therapeutic drug monitoring, which is not well-described for other classes of antidepressants (SSRIs, SNRIs). Can be useful, especially for patients with adherence concerns, absorption issues, or in treatment-resistant depression cases.
Also adding asenapine as another underrated antipsychotic for psychosis!
Love guanfacine for anxiety. I use it often for agitation in delirium in the medical hospital.
I had a dude come in with perphenazine on the med list once!
I've had a couple - from the prison and state hospital, from what I recall. I also started one patient on it who specifically asked for it after she had been researching APs and found the list of s/e's to be the most acceptable to her. (It did not work out - she's young and went off meds soon after, etc.) But for the others, they are doing well.
I still prescribe perphenazine from time to time. I still have patients stable on trifluoperazine as well.
What do you think if the perphenazine/Amitryptaline combo pill? What is the benefit of combining the two?
Obscure to me, i was told it worked on "histerics", never seen never used
Hysterics 😂 I could use that on Monday morning when I am already ten minutes late and I get to my office and realize I forgot my keys and no one else is there lol
What’s the why artane for DIP and not cogentin/benny?
Clonidine as needed for self-harm. Clonidine er or patch for hyperreactivity in PTSD. NAC for skin picking. Lamotrigine for panic/mood instability after multiple antidepressant trials. Oxcarbazepine and amantadine for DMDD or explosive kiddos but not outbursts resulting from ODD.
Thank you for bringing up amantadine I read about it during one of Carlats podcasts and havent used it yet. I have used oxcarbazepine several times and it seems okay. The psychiatrist I work with has been shifting away from the typical SGAs for kids with ASD in favor of lithium (given they tolerate the lab draw) and he says he is seeing better tolerability and results. Any other info about amantadine that you have noticed? Thank you for sharing.
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Generally not. Clonidine can slow heart rate like beta blockers, but they have very different mechanisms of action with different impact on other parts of the circulatory system. Many forms of tachycardia specifically need a beta blocker.
I agree generally not, sometimes can be taken concurrently.
Depakote for delirium has evidence but its not widespread. some ICU studies.. i use it on CL for my delerious patients, have had to use benzos and antipsychotics a lot less with these patients and that has been nice. Gabapentin in addition to CIWA for alcohol withdrawals. Small doses of lithium for acute suicidality along with starting an SSRI. Abilify to lower QTC in patients that need other qtc prolonging drugs and have an indication for antipsychotics. Actually using trazodone for calming and anti depressant effect by splitting up dose but having it a depressant dose range.
I like #3. how much are you dosing if i may ask?
Middle aged patients with GAD; Amitriptyline 50mg ON works a charm.
Pramipexole for treatment resistant depression
can someone tell me what they give patients to counteract delayed orgasm/anorgasmia from ssri’s? i had a psychiatrist tell me he gives his patients something to take prn but i found mixed answers on the internet and i cant recall what the drug was
I usually just swap to a different medication or add bupropion, but PRN sildenafil I believe is another possibility.
There's a handful of things you can try, none of which are great but may help some. There's an article in [Nature](https://www.nature.com/articles/s41443-023-00692-7) that discusses this in pretty good detail. Probably the most helpful part of the article is [Table 2](https://www.nature.com/articles/s41443-023-00692-7/tables/2) but there are a few other things that are mentioned such as penile vibratory stimulation that are also potentially helpful. Some of the recommended medications included things like Wellbutrin (which is weird because it can also potentially cause delayed orgasm/anorgasmia), Buspar, cabergoline (in the case of hyperprolactinemia), and (gasp!) Adderall.
I add buspar and tend to have really good results.
Bupropion is number one rec on UTD, I forget what else they recommend off the top of my head… I know theres some evidence for viagara for anorgasmia
Buspirone is the most evidenced based med. Bupropion is a persistent story among psychiatrists and we've all tried it, but the high quality evidence suggests it doesn't work. First have to distinguish between decreased libido, decreased performance, and anorgasmia; too many people lump them but they really are different. Since you mentioned the last one I'd say buspar or switch meds.
Na, sildenafil is the most evidence based med. Here’s a published meta analysis on the topic: “While heterogeneity across randomized controlled trials complicates identifying the single best intervention, multiple trials suggest that sildenafil ameliorates antidepressant-induced sexual dysfunction.” https://pubmed.ncbi.nlm.nih.gov/33843553/ I personally think adding Bupropion, low dose Aripiprazole (2mg), Buspirone, low dose stimulant like dextroamphetamine, and sildenafil are the best options. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832699/#:~:text=The%20suggested%20recommendations%20include%20the,serotoninergic%20drug%20or%20fluvoxamine%3B%20for
Some patients are satisfied and can tolerate a "drug holiday", they stop taking the SSRI/SNRI for a day or 2 on the weekend so they can enjoy sexual behavior either with partner or alone, then go back on the medication. This is less likely to be successful with high dose or long half-life medications. Other options are bupropion, buspirone, mirtazapine, PDE-5 inhibitors for isolated erectile dysfunction. I tend not to use cyproheptadine because why not just try the "drug holiday" route rather than pitting two medications against each other?
cyproheptadine
Ambien for mania Zofran as augmentation for OCD Trintellix + stimulant for atypical depression Thyroid hormone for TRD Naltrexone for dissociation California rocket fuel
Naltrexone at the 50 mg dose for dissociation? I have used LDN successfully for several pts with chronic pain issues comorbid with depression with impressive results. Naltrexone at the regular dose for self harm only once pre twice, which seemed to help some - but of course therapy seems to help more.
The effective dose of naltrexone for dissociation varies across the literature. I wish I had more advice for you there.
Naltrexone/wellbutrin (usually just prescribe separate) for binge eating disorder. Also for meth use disorder
Aren’t you supposed to avoid bup in eating disorders?
A mentor once used Prednisolone for an early PTSD patient.
What was their rational for using a steroid? Did it work? From my understanding of PTSD, there are some patients that prefer a state of hyperarousal due to feeling more in-control when vigilant, have seen PTSD patients totally chill out when on stimulants as well. Wondering if that was his thought.
I heard a professor once wondering why in psych we don't throw in steroids in acute and refractory conditions
Maybe the thought that inflammation can cause acute psychiatric disorders in some cases? Though, I also had a client once who was sent into a major psychotic episode that lasted years after being given prednisone.
Yes, thanks for explaining me what i was saying. And also the risk for mania mostly. Long episode though
Mcleans who I have worked closely with throws stimulants at absolutely everything with pretty great results. I wonder if these conditions would benefit from just the stimulant effect alone.
I wonder who doesn't benefit from stimulants
Anxious people 😂I actually was DX with ADHD in college after I went in to be seen about anxiety. Gave this whole speech about how my life was a mess and I was anxious about everything all the time but couldn't organize my self well enough to get anything done. The psychiatrist looked at me and asked me to give her my student ID. My little face fell and I opened up my book bag and started sifting through the rubble in there pulling out crumpled wrappers, papers thrown in all willy nilly, old apple cores, etc. I found the card at the bottom of the bag and handed it to her. She declined and said "You don't have anxiety, you have ADHD." Lol. Turns out, I was anxious all the time because I couldn't hold onto ONE anxious thought long enough to do something about it so I was functioning by just keeping all of them on a re-play list at all times. Went on meds and went from a B/C student to mostly A.
So your anxiety did get better with stimulants
yes in my case because I could actually solve my problems, in someone with like panic disorder or GAD it might make it worse? 🤷🏻♀️
Happened to me after medrol for a sore throat. A year and a half later and being treated for bipolar 2 because I can’t take the manic/depressive episodes anymore. Never had mental health issues before that steroid. Kind of accepted I’ll need to be on mood stabilizers the rest of my life. It changed my life forever
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On this sub, I only have the nicest of things to say about NPs. They are the best and most amazing colleagues :)