Involuntary grinding of teeth, which especially occurs during sleep but can also occur in the daytime. In 5% of cases this can cause severe health problems, such as destruction of tooth structure, temporomandibular joint dysfunction, myofascial pain, and sleep disturbances. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Clomipramine, which has more side effects than SSRIs, is usually considered a second-line medication for OCD. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Involuntary movements, usually occurring after months or years of antipsychotic treatment. The most common symptoms are oro-buccal-lingual, such as chewing, lip smacking, and tongue protrusion. Occasionally causes movements of fingers or toes and rarely, in severe cases, may affect torso and gait. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Triazolam gained notoriety as the benzodiazepine that may have caused President George Bush to faint at a state dinner in 1992. It is rarely used due to the higher likelihood for adverse effects (anterograde amnesia, psychiatric disturbances) compared to other benzos. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Like other Z-drugs, eszopiclone is an effective hypnotic with less potential for dependence than the benzodiazepines. Dosing is simple and, apart from the bitter aftertaste, its rapid onset and long duration of action make it well accepted among patients. As with all sedatives/hypnotics, nightly use should be discouraged. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Venlafaxine is probably somewhat more effective than SSRIs for depression, but its side effect disadvantages, such as blood pressure elevation and discontinuation symptoms, relegate it to second-line use. Venlafaxine’s active metabolite, desvenlafaxine, may be preferred by some over the parent compound—see our desvenlafaxine fact sheet in this chapter. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Rivastigmine is no longer the only cholinesterase inhibitor available in patch form, but it or the new donepezil patch may be advantageous for patients who refuse or have difficulty swallowing medication. Otherwise, we generally consider rivastigmine a second-line agent due to the need for twice-daily dosing and its high rate of nausea and vomiting. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Valbenazine was the first of the VMAT inhibitors to be approved for the treatment of tardive dyskinesia (TD) in 2017. Its advantage over off-label tetrabenazine is less frequent dosing (once daily) and less likelihood of causing depression. However, it is extremely expensive—about $7,000/month as opposed to $700/month for tetrabenazine. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Pitolisant is the only non-DEA-scheduled treatment option approved for patients with narcolepsy, but limited experience and data, plus a higher price tag, make it a second-line option after the “vigil” drugs. However, for patients with both cataplexy and excessive daytime sleepiness (EDS), it may be a better option than Xyrem, Lumryz, or Xywav. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Trazodone is most commonly used as a hypnotic at low doses (25–50 mg), but at higher doses it is effective for depression, and it has the advantage of fewer sexual side effects and less weight gain compared to other serotonergic antidepressants. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).