Dexmethylphenidate (Focalin) is the d-isomer of methylphenidate and is two times more potent than methylphenidate. Azstarys is a newly approved (and expensive) combination of Focalin and a prodrug version of Focalin—the Focalin is absorbed quickly while the prodrug is absorbed more slowly (it’s the Vyvanse of methylphenidate). There’s no clear advantage of Focalin over Ritalin—the main difference is that Focalin may mean fewer tablets for patients. Focalin XR only recently went generic, so it will likely remain quite expensive for a while. Azstarys may be less abusable than Focalin. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Aducanumab is an antibody that attacks and dissolves the amyloid protein that is thought to contribute to Alzheimer’s dementia. It is the first new drug approved for Alzheimer’s since 2003. Unfortunately, it is marginally effective at best, requires monthly IV infusion, has cumbersome monitoring requirements, and carries potentially significant side effects, all at very high cost. Until we learn more about its efficacy and side effects, we don’t recommend it. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Haloperidol is an effective, inexpensive first-generation antipsychotic with low weight gain potential and a long history of experience and use, but clinical utility is limited due to EPS and potential for TD. It’s favored by many clinicians for treatment of acute agitation, especially when given in an IM “cocktail” with lorazepam and diphenhydramine. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Melatonin is secreted by the pineal gland, and its rise in serum levels correlates with the time course of natural sleep. Short-term melatonin treatment appears to only modestly reduce the time it takes to fall asleep (about 12 minutes, which might not be considered clinically relevant) and does not appear to significantly improve overall sleep time. However, some patients report minor improvement in subjective feelings of sleep quality. It is cheaper than the melatonin agonist ramelteon (Rozerem); however, like ramelteon, it lacks good long-term safety data, especially with regard to effects on hormones. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Chlorpromazine was the first antipsychotic to be developed. Its long track record and good sedative properties make it popular for certain populations, especially patients with chronic psychosis, agitation, and mania, particularly when they are hospitalized. Its availability as an IM injection is an advantage for treating acute agitation. As a low-potency agent, it is less likely to cause EPS than many other antipsychotics. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Some research indicates that curcumin, the active ingredient in turmeric, may have benefits for cognitive health, depression, and anxiety. While it’s generally safe, its bioavailability is a significant issue, and more research is needed. It could be considered for patients with mild to moderate symptoms who prefer natural treatments. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Pregabalin is structurally related to gabapentin and is likely more effective for psychiatric disorders, especially generalized anxiety disorder and social anxiety disorder. It can also be helpful for patients struggling to discontinue benzodiazepines. Now that the generic is available, it’s no longer more expensive than gabapentin and preferable in most cases. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Atomoxetine is a non-stimulant ADHD treatment that carries no abuse potential, causes less insomnia and anxiety, and is unlikely to worsen tics. Unfortunately, it is generally less effective than stimulants and takes longer to work (two to four weeks). From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Cyproheptadine is sometimes effective in reversing SSRI-induced anorgasmia, but with continued use it could interfere with antidepressant efficacy. As-needed occasional use is the best strategy From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Daridorexant is the third agent in the class of orexin receptor antagonists. Like the other agents in its class, it is no more effective than benzos or Z-drugs, and it has a similar abuse liability. We’re concerned that next-day impairment is a potential side effect at the higher dose, particularly since sleepless patients may decide on their own to take even higher doses. It’s not a first-line hypnotic. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).