Quick list Dosing, as we do it

“A lot of people don't ever learn that after a patient leaves inpatient, the best thing to do is smush it all into, you know. One time a day dosing”

“A big lesson from this podcast, move all your antipsychotic dosing to once a day at nighttime. It makes a huge difference. It improves side effects that you wouldn't even expect it improves”

“The ones you need to take with food tend to end with Doan. So Ziprasidone is another one you really need to take with food”

“it takes anywhere from four to eight weeks to get to full steady state on a single dose of all three active molecules from Raylor. So it can look like it's not working a lot of the time if you simply start it at too low of a dose”

“Simply switching the agent, people can see a response where they didn't on a different agent. I think that's even more true for antipsychotics than it is for, say, antidepressants”

“I will start the new agent first to test tolerability, sometimes not even changing the dose to the existing agent if it's not at maximum. And then I will slowly go down by equivalent chlorpromazine doses”

“Seroquel is the one that if you're switching from it, you should probably just leave it and titrate on the other medication and then pull off. And then another factor to consider is partial agonists have the highest binding affinity”

“I really hate the practice of adding it to Haldol. You're basically making the medications fight each other because it binds so tightly to dopamine receptor that it essentially counteracts a lot of other antipsychotics”

“Well, first of all, they started at 15 milligrams, and then they easily went up to 30 milligrams pretty quickly. And on top of that, they used benzodiazepine. I believe it was lorazepam as a PRN, and it was basically on board”

“Do not dose-abilify above 5 mg if what you are trying to do is trying to treat major depressive disorder without psychotic features. Do not do it. Just don't do it. It's not worth it”

“You should probably start around 15 and no lower than 10 milligrams. I've seen people respond with lower, but remember, what does that partial agonist mean? It basically means that about 20% of the dopamine receptors that it is bound to is not blocking”

“Abilify. Keep in mind that with Abilify, they did minimum 15 and all the way up to 30 to get the antipsychotic response in the original trials. And they gave it benzodiazepine as well”

“it's got a three-day half-life. Whenever you're thinking about half-life, that means steady state you have to multiply by five because it takes five half-lives to get there, so steady state takes two weeks”

“Aripiprazole is one of those medications that I'm more likely to dose in the morning because stimulation can outweigh sedation for a lot of patients”

“So if you have a patient that skips several of their doses every week but is still taking their medications several times a week, don't be afraid to use a higher dose Abilify. Let's say they're stable on Abilify 15 in the hospital. We'll give them Abilify 30 and they take it three or four times a week”

“2D6 inhibitor, and thus can be used to increase effective dose of your Abilifying antenna and Aristata, which maxes out at a 15 to 20 milligram daily dose”

“Don't use the short acting ones because that's going to make the possibility of forming addictive behavior worse. Personally, I would either do clonfin or valium”

“we're going to talk about the plan to see how we can reduce or stop the dosage over a period of time that's equivalent to the total time that they've been on the benzodiazepine or two years if they've been longer than two years. That's my general rule. It's not evidence-based”

“especially when someone has been on longstanding benzos. We have basically induced iatrogenically as physicians. We have doomed them to a state of physiological change that may be permanent. They just have to be on those benzos. OK, it's not a good thing”

“there was like a recent big study that showed that there's a higher mortality in patients who discontinued long-term benzos. So it's, you know, there is genuine risks in tapering patients off of benzos. And those need to be genuinely considered”

“if people come off a benzodiazepine, they tend to have greater self-confidence, better concentration, less depression, and all that's from clinical observational studies. That correlates with what we see on the PET scan, which is that the brain is healthier six or 12 months after coming off of benzodiazepine”

“I like to start with a half milligram dose, and I say take one or up to two at a time. Call me if you need more than one milligram of the day and I give 30 or 60, whatever I kind of feel like”

“I think the big lesson I'm taking from you is pushing the dose, starting at higher doses than I used to start”

“It's deceptive because it comes in seven and a half, right? Makes you think you should start there. But really that's where titrating up once you're already at the starting dose of 30 a day. and divide the doses naturally”

“Low-dose buspirone, as I mentioned, like an SSRI, is more serotonin agonism and seems to cause sleep disruption. Sleep disruption. This is at total daily doses below 20 milligrams. It's one of the reasons why I usually try to start at total daily dose of 30 milligrams, 15 and 15”

“you want to start at minimum 15 in the morning, 15 at night. That's the starter dose. Now, what I do say to patients is that if this happens to make you very sedated, then cut the morning dose in half or stop it”

“make sure you're giving it at least twice a day. The half-life is relatively short, and you need to reach an adequate serum level. So twice a day is minimum, you're probably not going to get very much out of it if you're not doing it at least twice a day”

“it goes from 15 to 15, 15 and 15 to 15 and 25, for example, and then 25 and 25. OK, and then at that point, you're about 10 milligrams down from the typical FDA daily maximum”

“And it's not a as needed medication. It's not a PRN. It's something that takes a few weeks to kick in just like the SSRIs and the SNRIs”

“You have to head for 600 from the get-go and get there quite slowly. A 200 milligram pill, or if I'm really anxious and I really want to make sure that the patient doesn't have trouble with this and we're not in a super big hurry, A 100 milligram increments from zero to 600”

“Weird, because it has two, count them, two active metabolites, so it takes anywhere from four to eight weeks at one dose to reach its maximum efficacy”

“If the patient's been off of it for more than 48 hours, you need to restart the titration. The REM requirements have gone away, so you don't need to log into the database. That doesn't mean that the monitoring has gone away”

“You have to wait five days after dose change before the levels are appropriate in their blood. The typical target plasma range is 350 to 600. You can go above 600, but there's really diminishing returns above 1,000”

“you can also check it whenever you add new medications to sort of make sure there's not interactions. And there's things you wouldn't expect, like if a patient's drinking orange juice and they switch to grapefruit juice, that can impact their levels a lot”

“I typically say, let's start at three milligrams. If you're having issues, go up to six. I see variable, like for some patients, three milligrams totally knock them out. For some patients, they need the six milligrams”

“you tell the patient to get just a little tiny syringe that is one milliliter. And then each little cutoff is a milligram and three milligrams. You just suck up the little liquid and it's covered”

“Low dose Doxepin. And yes, you can just give a 10 milligram capsule. You don't have to be all cute and get to four and eight milligrams. It's not going to be more effective like that”

“Maybe it's ten. Oh, sorry. It's ten milligrams. And I told the patient to cut it in half. Yeah. Yeah. It doesn't work as well. The patients don't have the same experience”

“Zoloft 50 milligrams is my minimum effective dose for the average patient. And then Lexapro, I have somewhere between 5 and 10 as the minimum effective dose”

“Lexapro, if I'm not in any sort of rush, I usually do the same thing with a 5 milligram. So I'll say take 2.5 for one week and then go up to 5. And that's just because I've had a lot of patients have more difficulty tolerating Lexapro if I go 5 to 10”

“I get them to 10 pretty fast. It's just it's almost psychological on my part in that, you know, it's I've had problems with getting five milligram tablets from pharmacies locally. So often I don't have that option”

“it only has four titration steps, unfortunately, which I don't like. I like to have more steps. I think that works psychologically. Physiologically”

“studies needed much higher doses than what I see it be used at to show an effect on anxiety. I feel like all the time you see people on 100 milligrams, 300 milligrams of Gabapack”

“I try to cap it at 1,200 personally. I feel like, what are you doing at that point? Just separate it out into a different dose. Do I give a lot of gabapentin for anxiety disorder? No, but I'm not opposed to it”

“I'll start with 300 and I'll say, if it's not enough, go to 600 and call me. And if it's way too much, call me and I'll send you 100s. So basically starting on 300 and then titrating to effect”

“Haldol and Risperdal have the same chlorpromazine equivalents in terms of milligram dose. Okay. One milligram of Haldol is roughly equivalent for a D2 blockade to one milligram of Risperdal. But for some reason, no one ever starts on 5 milligrams of Risperdal. But they routinely start Haldol on 5 milligrams”

“Don't be afraid to go up to, you know, 10, 15 milligrams in very rare cases, but most of the time they will respond below eight milligrams, just like Risperdal”

“I really pay zero attention to it and have not found a difference in my practice. I just prescribed. I don't even know what I'm clicking on. And in my opinion, from what I reviewed in the past, and I didn't review it very long, there was no evidence to show a difference”

“You should absolutely follow the rules. Do not titrate. You'll see a slower titration schedule depending on whether you're dosing the same time as an inhibitor of its metabolism, like Depakote, for example, or with other considerations. But follow that protocol and warn, warn, warn”

“Don't linger on lower doses, in my opinion. If you're going to use it, get it to 200. It's so well tolerated, okay, and you get benefit. But also, don't be afraid to go above 200 either. You can technically go to 400”

“valproic acid jacks up the levels of lamotrigine. So the way I remember it is when you combine those two medications, it's the dangerous interaction. So increasing lamotrigine is what we're scared of because of SJS. So whenever you're interacting using those medications, you should half the lamotrigine”

“I say start with one pill for a week and then you can move up to two pills. I think that's like 160 milligrams. In terms of the effect I see, almost everyone is like, oh yeah, it really helped me”

“people love it for the first few months and then it kind of poops out. So usually by like six months, they don't see any sort of significant difference”

“Starting with 150 milligrams, because that's the smallest dose we can engineer, and going up by 150 milligram steps every four to seven days and nights. Until something good happens, something bad happens, go back down one step, or you get to 600 milligrams daily and then check a level”

“So the first thing that I would say about lithium is that you should try it at And around 450 milligrams nightly on an ER”

“There is not a narrow therapeutic window for lithium. There's a narrow therapeutic window for lithium if we're treating acute mania. Okay, that's the key. That's the key. So when it comes to treating lower acuity conditions or in the long term, you can see clinical improvement, even if it's not perfect, with lower doses of lithium”

“Adjunctive treatment with lithium or for mild bipolar, anything in the 0.4 to 0.7 range is actually fine. You don't have to do the old manic dosing”

“maintenance is considered the 0.6 to 0.8 range. 0.8 to 1.2 is considered acute mania. Now that doesn't mean that you're protecting mania. That means the patient is actively manic. That's when you push up to 0.8 to 1.2”

“the onset of effect of lithium takes at least two weeks most of the time. So that's the problem with the mood stabilizers. I think that's why a lot of people don't use them today, because they want instant gratification as a clinician and a patient. You have to set expectations”

“I will titrate Up to the range of around 750 or even 900 depending on the reported adverse effects even without the first lab draw. But this is because I'm in a low resource clinic where despite my efforts many people will refuse or be unable to get lab draws”

“do not trust the Invega Sustenta label saying that you do not need an oral bridge in the first month when you load. OK, you do need an oral bridge because all they're saying is that by doing the loading dose, you have a clinically significant amount of the paliperidone in the system in that first month”

“I always give A one to two week, at least three quarters bridge dose and then drop it off slowly every two weeks from there”

“Though I do find in the three-month and six-month forms of Invega LAI that some people do need to get it a little bit earlier”

“needs to be taken with 350 calories or else the patient will get half the dose. It is something you actually do need to talk to patients about”

“And the main drawback is actually the 500 calorie absorption requirement that not everyone can routinely do that up to twice a day, which you might need on zaprazodone compared to the trazodone”

“And melatonin, in that case, you got to remember, has double effect, right? It has an effect on sort of regulating the sleep clock and also has a sedative effect. You may want to be using it earlier than you'd think several hours before the intended bedtime”

“Oftentimes patients use it at way higher doses than they should be. I think studies have shown like 0.3 to 1 milligrams is the ideal dose”

“The proper dose is 15 milligrams a day, which is available through several products on Amazon for just about $5 a month. So your patients can now afford it where it used to be difficult”

“I don't recommend testing for any of these. And that's in some ways where the hypothesis falls apart. And the other hole in this hypothesis is that most of the trials, in fact, nearly, well, most of the trials have enrolled people without testing for a deficit”

“The time to peak for most of the antipsychotics is two to three hours. For olanzapine, six to eight hours. So for many people, it's better to try taking this earlier in the evening”

“I've also had the off guy who comes in on 40 of olanzapine and I'm like, that's a lot of olanzapine. Let's see if we can go down a little bit. And I move it down five milligrams to 35 and then he decompensates”

“there are about, I remember about 30 controlled trials of omega-3 and depression. And they only show a benefit if we look at the ones that used high levels of EPA. The analyses are now recommending that it have at least twice as much EPA as DHA”

“You're also more likely to respond to, I should say, to need higher doses of omega-3. There is a study showing that you had to go higher if you had inflammation all the way up to 4,000 milligrams a day of the EPA and the DHA, where most people take 1 to 2,000”

“In terms of adverse effects and tolerability, the only real downside is that you do have to give it at least twice a day, in my opinion”

“Though I do find in the three-month and six-month forms of Invega LAI that some people do need to get it a little bit earlier”

“Don't forget that how much prazosin you're supposed to use depends a lot. on the individual, right? When they did the study on male veterans, mostly male veterans, I believe they were going up to seven or eight milligrams, pretty high”

“I'll typically use like 20 to 40 milligrams of propranolol, tell the patient to use it an hour before the performance or whatever the anxiety provoking situation is. And what it tends to do is it just really suppresses that autonomic response”

“Long term, I do prefer to put people on propranolol. twice a day. You can get effect from as little as 10 milligrams twice a day for akathisia. If the akathisia is more like a restless legs thing that's mild and only at night, gabapentin can be quite effective, nighttime gabapentin”

“at low doses, it's a sedative at 50 milligrams and below. It's really just hitting the histamine at the 300 milligrams and below. We think about it as more of the mood symptoms. And then above 400 is when you start to get that D2 blockade”

“Well, should you really have the sedation of Seroquel for 24 hours a day? I don't think it's a good idea. So frankly, I don't think there's any good reason to do XR. And it also blunts the benefit of Seroquel's peak early on in the night to do sleep”

“Haldol and Risperdal have the same chlorpromazine equivalents in terms of milligram dose. Okay. One milligram of Haldol is roughly equivalent for a D2 blockade to one milligram of Risperdal. But for some reason, no one ever starts on 5 milligrams of Risperdal. But they routinely start Haldol on 5 milligrams”

“It's kind of variable and it's half-life for people. So that's probably, in my opinion, this is a theory why some people actually need risperidone twice a day and some people don't”

“I'll start at 25 milligrams for a week and then move up to 50, stay there for a month, and then negotiate an effect. I usually will prescribe 30 of the 50 milligrams and say break the first four and a half”

“Zoloft 50 milligrams is my minimum effective dose for the average patient. And then Lexapro, I have somewhere between 5 and 10 as the minimum effective dose”

“It really depends on the severity of the depression and how soon I can see the patient. So let's pretend we can see people in four weeks and it's moderate severity, right? For that, I would probably try to get them to 50 milligrams before the next visit”

“what I like about doing the step from 100 to 150 is that you can say, listen, if this doesn't work out for you, take the 100 and half of the 50, giving the patients real control”

“It has few interactions. It is many There's many those types. Titrations and it works. And guess what? If you have OCD, you can even take it above 200 milligrams, but do so with caution”

“As needed dosing as people who have listened to the other episodes know, I'm not really a fan of that. If it's worth taking a medication, it's worth taking it every night”

“find out if they've had anything like it before. And if they have, then you'll know. around what kind of dose they might start to see effects from. And if they haven't, then start low, go slow, but try to follow up soon so that you can address anything that's going on”

“It really depends on the severity of the depression and how soon I can see the patient. So let's pretend we can see people in four weeks and it's moderate severity, right? For that, I would probably try to get them to 50 milligrams before the next visit”

“I get them to 10 pretty fast. It's just it's almost psychological on my part in that, you know, it's I've had problems with getting five milligram tablets from pharmacies locally. So often I don't have that option”

“the people who might have a little bipolarity, even if they'll never have a real bipolar disorder or have very high levels of anxiety, then yeah, going too quickly on the medication like Lexapro can definitely, uh, cause some reactions there”

“it's completely variable. Patient to patient, You never know what's going to happen necessarily. So I often tell patients, if it makes you sleepy, take it at night. If it activates you, take it during the daytime”

“It's long lasting. Good for sleep maintenance. Now the time to onset isn't great. So you do have to take it on like a timer, you know, one or two hours before your desired bedtime”

“Additionally, if they're not very sensitive to trazodone, they can take a very high dose. I can take it up to 200 plus, and now it's an antidepressant too”

“And the main drawback is actually the 500 calorie absorption requirement that not everyone can routinely do that up to twice a day, which you might need on zaprazodone compared to the trazodone”

“Geodon, if you need a high enough dose, you're not going to absorb enough. in one meal, so you might have to go to BID”

“Do not dose-abilify above 5 mg if what you are trying to do is trying to treat major depressive disorder without psychotic features. Do not do it. Just don't do it. It's not worth it”

“When I'm consenting somebody for ECT for major depressive disorder, I expect them to do 12 treatments. We try to do three treatments a week”

“in a disease like catatonia, the answer is you're going to do ECT treatments three times a week until you're not catatonic. That might be one treatment. That might be 12”

“we treat whatever side of the disease phase that we're in, we treat to symptom remission plus three”

“Once we get done with ECT, the goal is to stay in remission. So typically what we'll do, I'll have somebody come back for maintenance treatment one month after they finish their index course”