Psychopharmacology and Psychiatry Updates

In this episode, we explore lumateperone for treating major depressive episodes with mixed features – that challenging presentation where patients experience depression alongside racing thoughts and restlessness. Can we effectively treat both the despair and the activation without triggering mania? Dr. Kristin Raj examines the evidence and clinical implications for this understudied population. Faculty: Kristin Raj, M.D. Host: Richard Seeber, M.D. Learn more about our membership here Earn 0.75 CME: Quick Take Vol. 76 Lumateperone for Depression with Mixed Features: Is It Effective?

Dr. Lauren Osborne, a perinatal psychiatrist from Weill Cornell Medicine, dives into the intersection of antidepressants and breastfeeding. She reassures listeners that most psychiatric medications are compatible with nursing mothers. They discuss how postpartum women often respond more quickly to treatment and the importance of selecting medications based on prior successes. Dr. Osborne highlights the factors influencing how drugs enter breast milk and stresses that maternal treatment needs should take priority, especially for vulnerable infants.

Scott Beach, a psychiatrist and expert commentator, shares insights from a crucial case-control study on QT prolongation linked to psychiatric medications. He discusses the rarity and unpredictability of torsades de pointes, revealing that single antidepressant or antipsychotic use shows no significant risk, while polypharmacy does. Beach emphasizes the importance of careful monitoring of QTc values and addressing reversible factors, urging clinicians to avoid knee-jerk reactions in medication management for psychiatric patients.

Dr. Lauren Osborne, a perinatal psychiatrist from Weill Cornell Medicine, unpacks the complexities of postpartum OCD versus postpartum psychosis. She reveals that while intrusive thoughts about infant harm are common in OCD, they indicate serious risks in psychosis. The conversation includes effective ways to ask mothers about these thoughts safely and highlights key diagnostic differences. Dr. Osborne emphasizes the importance of accurate diagnosis for proper treatment and safety, providing insights into effective therapies for both disorders.

Dr. Paul Zarkowski, a psychiatrist and researcher known for his analysis of the STAR*D trial data, dives into the controversial belief surrounding SSRI side effects. He discusses whether these effects truly diminish over time, revealing that some patients may actually face worsening symptoms. Zarkowski explains concepts like survivor bias and presents data showing distinct side-effect trajectories. He also highlights persistent problems such as sexual and sleep-related side effects and stresses the importance of early assessments for effective patient counseling.

David Osser, an associate professor of psychiatry at Harvard Medical School and psychopharmacology expert, shares his insights on treating acute mania. He discusses effective strategies for augmenting lithium, highlighting quetiapine as the preferred add-on due to its mood-stabilizing effects. Osser critiques the overuse of valproate and explains the minimal benefits from combining it with lithium based on the BALANCE study. He also warns of metabolic risks associated with drug combinations, providing vital considerations for patient care.

Join psychiatrist Oliver Freudenreich from Harvard Medical School as he dives into an innovative Mayo Clinic algorithm for selecting antipsychotics for first-episode psychosis. He discusses how the presence of violence influences the choice of medication, recommending options like aripiprazole and olanzapine. He emphasizes the effectiveness and adherence benefits of long-acting injectables and defends olanzapine’s use despite its metabolic risks. The conversation culminates in a practical application of these insights to real cases.

Dr. David Osser, an Associate Professor of Psychiatry at Harvard Medical School and expert in bipolar treatment, argues for lithium as the first-line therapy for classic mania. He presents compelling evidence of lithium's neuroprotective benefits and long-term efficacy, emphasizing its role in reducing suicide risk and preventing episodes. Comparisons of second-generation antipsychotics reveal their limited advantages over lithium. Osser’s insights challenge the reliance on antipsychotics, advocating for lithium's unique advantages in managing bipolar disorder.

In this episode, we explore a head-to-head comparison of trazodone, doxepin, and melatonin for treating insomnia when benzodiazepines are off the table. Which non-benzodiazepine sleep aid offers the best balance of effectiveness and tolerability in real-world psychiatric patients? Faculty: Paul Zarkowski, M.D. Host: Richard Seeber, M.D. Learn more about our membership here Earn 0.75 CMEs: Quick Take Vol. 74 Melatonin, Trazodone, or Doxepin for Sleep Disorders

Dr. David Osser, Associate Professor of Psychiatry at Harvard Medical School, shares his expertise on managing mixed manic episodes. He discusses the critical timing for adding lithium or valproate to antipsychotics, emphasizing patience and evidence-based strategies. Osser cautions against rushing into combination therapies due to managed care pressures and advocates for temporary use of benzodiazepines to stabilize patients. He weighs the pros and cons of lithium versus valproate and considers carbamazepine as a viable third-line option.