Medication updates

By Alan Koenigsberg, M.D.

I subscribe to and read several medical journals. Some are weekly, such as the New England Journal of Medicine and the Journal of the American Medical Association. Others are monthly, such as the Journal of the American Psychiatric Association, Psychiatric News, The Medical Letter and the Carlat Report on Psychiatry.

As an acknowledged dinosaur, I receive all of these journals in print format, as well as electronically. I enjoy spending time over a cup of coffee, at a local establishment, quietly reading these journals. It’s how I keep up with the changes and progress in the field of general medicine, as well as my specialty of psychiatry.

Lifelong learning was impressed upon us both as medical students and as residents and has been my practice since I graduated.

This past week, several articles caught my attention, because there are not that many which show the lack of efficacy of specific treatments or perhaps the drawbacks of some treatments. I will share some of them here.

One article discussed the decrease in the use of lithium in the treatment of bipolar disorder. Part of the putative explanation was that since the approval of an antipsychotic in 2000, other medications have been used to treat people with bipolar disorder.

While this practice is a valid one, there are clear benefits to using lithium. It may take a bit longer to fully kick in, but most patients also describe feeling better and being less sedated than when taking an antipsychotic medication. There are more monitoring tests needed when taking lithium, which may be another reason for reticence in using it.

I have found that in my practice, with my patients with bipolar disorder, it has worked well with minimal concerns about ensuring that lab tests are done appropriately.

Another article of interest is a recent study regarding ketamine in the treatment of depressive disorders. The industry sponsored study showed that esketamine treatment worked well within 24 hours, but the benefits faded rapidly and within four weeks, there was no improvement. It could be that repeated treatments are needed to sustain the benefits, as is the case with most treatments, but the idea that one treatment would provide lasting benefits was not seen in this study.

Now for a different set of treatments: those for people who suffer from insomnia. Decades ago, we prescribed barbiturates to help people sleep. These treatments have been completely replaced by the benzodiazepines and similar “Z” medications, such as clonazepam and zolpidem.

I have been prescribing both of those for many of my patients suffering from chronic as well as episodic insomnia, for decades. For the most part, they work well.

There are many other medications that we use, such as trazodone, which is quite sedating. The downside to most of these medications is twofold: potential interactions with other medications and the risk of misuse.

A relatively new class of medications to treat insomnia came onto the market in 2014, called Dual Orexin Antagonistic medications, DORA. Orexin is a neuropeptide produced in the hypothalamus part of the brain and promotes wakefulness. Narcolepsy appears to be caused by a lack of orexin-producing neurons.

Orexin is also involved in appetite and it may be that further research will show benefits in that area.

I have prescribed one of these to a few patients during the last few years and have found it to be safe and effective, especially in older patients. The only potential drawback to prescribing these medications is cost. While they could indeed be used as first-line medication treatments, many insurance companies will not pay for them unless the older, less expensive medications have been tried first and failed, for whatever reason.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas. He can be reached at

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