Key moments, in order
- 2:47
Consider metabolic side effects first, rather than just what works. Keeping a young patient on a weight-gaining antipsychotic without trying alternatives puts them on a highway to diabetes, high cholesterol, heart disease and over-sedation.
- 6:03
Weigh your patients; in telehealth, have them weigh themselves and report. Waist circumference is the gold standard.
- 8:26
There is some theory that it works better in people with a less disturbed dopamine system, meaning earlier in the illness or without much long-term stimulant use.
- 8:49
It is metabolically pretty clean: minimal weight gain, minimal QTc prolongation and low prolactin. Along with ziprasidone, it is probably the best second-generation choice for avoiding weight gain.
- 9:45
The pines (olanzapine, clozapine, quetiapine) are by far the most metabolic. The dones vary, with risperidone in the middle.
- 10:54
After aripiprazole, lurasidone and ziprasidone are probably the best second-generation choices for little weight gain, and cariprazine has not caused much either. We draw the line at aripiprazole and try nothing more metabolic unless we really have to.
- 12:00
Everyone is an individual: a drug that works great in 90% of people may work terribly in one, and some people gain weight on aripiprazole. Do not tell a patient starting Abilify they will not gain weight, or they will stop trusting you.
- 13:06
Some weight gain is a treatment effect, not a drug effect: many people do not eat when they are in emotional distress and start again as they recover.
- 14:16
Population numbers cannot tell weight gain caused directly by the drug from weight gain as a consequence of treatment. In one analysis, accounting for unhealthy eating made the SSRI weight signal mostly disappear, which is not true for heavy gainers like olanzapine.
- 15:30
Most antipsychotics do not need twice-daily dosing, yet patients leave the hospital on BID and stay on it for years. After discharge, consolidate to once a day.
- 16:51
Move all antipsychotic dosing to once a day at night. It covers the psychosis and the sleep, keeps patients more active and less sedated by day, and improves side effects you would not expect.
- 18:07
Do not sugarcoat the medications. Empathize with how annoying they can be, and stay hopeful but realistic.
- 19:27
What looks like a patient's baseline may be sedation. When we brought sedation down a little, some patients almost changed personality; one worried she was getting manic, but she was just getting back to normal.
- 21:09
All the symptoms funnel into social and occupational functioning, and maximizing function is the real focus. Some people are fine with more hallucinations if they are less sedated, and that does not mean they will be hospitalized; assess the patient.
- 23:30
Pick weight-sparing medications when possible, knowing the trade is often akathisia. Lurasidone is number one for akathisia and aripiprazole is up there; newer drugs that help mood and spare weight still cause a lot of it, and it is a big reason people cannot take them.
- 23:51
Plan ahead. If a patient has a history of akathisia, even on the less akathisia-prone drugs, or is worried about it, give PRN benztropine: take this if you become restless.
- 25:12
The same doctors who say never prescribe benztropine will give olanzapine and quetiapine without blinking, and those are already anticholinergic.
- 26:10
For the long term, propranolol twice a day is preferred, with effect from as little as 10 mg twice a day. If it is mild, restless-legs-like and only at night, nighttime gabapentin can be quite effective.
- 27:16
Start with 0.5 mg tablets, one or up to two at a time, and ask the patient to call if they need more than 1 mg a day. Dispense 30 or 60.
- 30:02
Check for standing benztropine that nobody has questioned. On clozapine, for example, you would not expect EPS, so there may be no reason for it; tapering it off can make no noticeable difference and may spare future cognitive problems.
- 31:06
All anticholinergics are potentially unhealthy, and we give tons of them without calling them poison. Benztropine is perfectly fine; just do not give a medication people do not need.
- 31:51
Use antipsychotics sparingly and only as the clinical picture needs. Abrupt withdrawal dyskinesias can happen, and they may go away or persist.
- 33:23
Find common ground in concentration, sleep, fear or stress, and say honestly that the medication helps those: it makes thinking more organized so they can concentrate and live their life better.
- 34:43
Come to a shared agreement about what you are targeting and why you are making changes.
- 35:09
Establish from the outset, and maintain, that the patient is the primary agent in the treatment, even if they are conserved. Ultimately we want people to take medications voluntarily and knowingly.
- 36:20
Other reasons for hesitancy: there are not many injectable choices, and most cause a lot of weight gain.
- 37:22
LAIs have been shown to decrease hospitalizations and non-adherence, and choosing a shot once a month is far easier than choosing to take medication every day.
- 37:54
They are not always the answer. LAIs often cannot achieve the right dose, and some patients respond at higher serum levels than an injection allows, so moving them to an LAI may deprive them of that.
- 42:02
You pick how conservative to be: conservative practice means more patients on unnecessary medications, but more stable patients.
- 43:46
Before adding a second antipsychotic, go back to the diagnosis and look for mixed features or other psychopathology beyond the psychosis.
- 44:59
Add a mood stabilizer to an antipsychotic regimen, probably before a second antipsychotic, when mood features are prominent, even in long-standing dual-antipsychotic regimens. Lithium and lamotrigine bring improvements the antipsychotic class cannot. If you must add a second antipsychotic, pick one that is appreciably different.
- 45:35
When treatment fails, the first reason is the wrong diagnosis. Before adding a medication, ask what the diagnosis is.
- 47:26
Simply switching agents can bring a response where there was none, even more so than with antidepressants.
- 48:15
To switch, start the new agent first to test tolerability, then slowly come down on the old one by chlorpromazine equivalents.
- 50:15
Coming off quetiapine, leave it in place, titrate the new drug on, then pull it off. Remember that partial agonists have the highest binding affinity.
- 50:43
Do not add it to another antipsychotic, especially haloperidol. It binds so tightly to the dopamine receptor that it counteracts the other drug, so adding low-dose aripiprazole takes antipsychotic away rather than adding more.
- 51:08
There is only one stronger antipsychotic, and it is clozapine. If you can do clozapine, try it. It is a miracle drug if you can get someone to take it and do the monitoring, but most people cannot because of the monitoring, and many do not like the side effects.
- 54:15
Low-dose aripiprazole in an acute phase is not what the trials tested. They started at 15 mg, went up to 30 pretty quickly, and had a benzodiazepine (lorazepam as needed) on board.
- 54:49
Food, food, food, and dinnertime. It does not absorb without at least 350 calories, or the patient gets half the dose, and it seems better tolerated once at night. You do need to talk to patients about this.
- 55:29
You really need to take it with food: the main drawback is the 500 calorie absorption requirement, which not everyone can meet routinely. The antipsychotics that need food tend to end in "-done".
- 55:58
It has two active metabolites, so it takes four to eight weeks at one dose to reach full steady state and maximum effect. It can look like it is not working if you simply start it at too low a dose.
- 56:45
Haloperidol and risperidone are one to one in chlorpromazine equivalents for D2 blockade. Nobody starts risperidone at 5 mg or takes it past 8, yet haloperidol is routinely started at 5 mg and pushed to very high doses.
- 57:24
Because of prolactin, do not be so gung-ho giving it to female patients. You can get away with adding low-dose aripiprazole to bring prolactin down.
- 58:07
Paliperidone and risperidone are by far the antipsychotics most likely to raise prolactin.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.