Ramelteon is a melatonin receptor agonist. Compared to other hypnotics, ramelteon poses a lower risk for respiratory depression and hangover effect (morning grogginess). It’s a good agent to have in your bag of tricks, but consider the possibility of rare hormonal effects. Also consider that over-the-counter melatonin (which ramelteon mimics) may do the same job, possibly at a lower price. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Clozapine is the only drug with convincing evidence of superior efficacy over other antipsychotics for treatmentresistant schizophrenia. Consider using it after two failed trials of other antipsychotics. Side effects can be a real challenge, including severe weight gain, constipation, drooling, sedation, and potential neutropenia. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Successful marketing has convinced the public that “low T” is a public health scourge, leading to over-prescribing of testosterone for patients who don’t need it. Prescribe it only for men with demonstrably low testosterone levels and accompanying symptoms. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Trifluoperazine, like thiothixene (Navane), is an effective older agent with similar potency to haloperidol or fluphenazine; however, given all our antipsychotic options, it sees only rare use these days. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

The efficacy of VNS remains too controversial to recommend its use in all but the most desperate clinical situations. Noninvasive VNS devices may become available for depression treatment in the future. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Sertraline is a good first-line SSRI option for many patients due to its range of indications, flexible dosing, low drug interaction potential, and relative tolerability. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Valproic acid is the go-to antimanic agent for acute manic episodes, featuring faster onset of response and better adverse effect profile compared to lithium, fewer drug interactions than carbamazepine, and efficacy for rapid cycling and relapse prevention. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Brexanolone is a novel, fast-acting option that is given intravenously for patients with severe postpartum depression. However, its utility is limited by the lengthy infusion (60 hours) in a health care setting, potential for severe reactions and associated need for close monitoring, high cost ($34,000 for the drug alone, plus costs associated with providers and health care facilities), and lack of follow-up data beyond 30 days. Zuranolone, a new orally available neurosteroid, provides a safer and easier option for this indication. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).

Suvorexant is an orexin receptor antagonist, and as such it treats insomnia differently from existing agents (though lemborexant and daridorexant have since followed in its footsteps). Other than a new mechanism of action, suvorexant doesn’t have any clear advantages. 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 highest approved dose of 20 mg, 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).

Due to its longer half-life, clonazepam causes fewer breakthrough symptoms compared to alprazolam when used for anxiety. May also work as a good short-term hypnotic, although development of dependence and long half-life limit this use. From Medication Fact Book for Psychiatric Practice, 7th Edition (2023).