The Carlat Psychiatry Podcast The Carlat Psychiatry Report

This week we’re podcasting from the International Society for Bipolar Disorders 2020 conference, where we’ve been scouring the virtual halls for all that is practical and newsworthy. The yield is high so tune in for a new episode every day. Today, a poster presentation from the Mayo Clinic challenges conventional wisdom about whether to stop lithium in the face of renal decline.
Published On: 7/3/2020
Duration: 5 minutes, 42 seconds
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This week we’re podcasting from the International Society for Bipolar Disorders 2020 conference, where we’ve been scouring the virtual halls for all that is practical and newsworthy. The yield is high so tune in for a new episode every day. Today, unpublished findings on the first solo psychotherapy study in bipolar II.
Published On: 7/2/2019
Duration: 4 minutes, 15 seconds
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This week we’re podcasting from the International Society for Bipolar Disorders 2020 conference, where we’ve been scouring the virtual halls for all that is practical and newsworthy. The yield is high so tune in for a new episode every day. Today, new results on an anti-inflammatory medication in bipolar depression.
Published On: 7/1/2020
Duration: 3 minutes, 36 seconds
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The first clinical trial of a modified diet for bipolar disorder in this daily dispatch from the International Society for Bipolar Disorders 2020 conference.
Published On: 6/30/2020
Duration: 7 minutes, 50 seconds
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Daily dispatches from the International Bipolar Disorders Conference. There are four atypical antipsychotics that treat bipolar depression, but which have the best balance of efficacy and tolerability?
Published On: 6/29/2020
Duration: 5 minutes, 15 seconds
Transcript:
Will the Best Atypical Stand Up?
This week we’re podcasting from the International Society for Bipolar Disorders 2020 conference, and there’s so much here that we’re trying out a new format. We’ll bring you a new episode each day. If you like the daily format, leave us a review in your podcast store and we’ll keep up the pace if we get enough shouts.
Today, an unpublished paper from Leslie Citrome and colleagues on how the atypical antipsychotics measure up in bipolar depression.
Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
We have four atypicals that work in bipolar depression: cariprazine, lurasidone, olanzapine-fluoxetine combination (or OFC), and quetiapine. Among them, only OFC is supposed to be used with an antidepressant ─ that’s the only way they got olanzapine to work in the clinical trials ─ the other 3 work on their own.
Now if you’re thinking that the other atypicals probably work because these four do, you’re betting on hope. Two of them ─ aripiprazole and ziprasidone ─ were tested in bipolar depression and failed. The others are untested. If we have to rest our hope on one, maybe it’s asenapine (Saphris). Asenapine has never been studied for acute bipolar depression but it does have good evidence to prevent depressive episodes in bipolar disorder, while the other atypicals ─ outside of the FDA-approved four ─ do not.
So that’s what works, but how well do they work? Leslie Citrome and colleagues looked into that question with the Likelihood to be Helped or Harmed ratio – which tells us which med has the best ratio of efficacy and tolerability. It’s based on the more familiar Numbers Needed to Treat or Harm. Here’s what they found:
Lurasidone (Latuda) rose to the top in nearly every category.
The “categories” were based on the side effect. When we’re talking about efficacy, we’re talking about one thing: treating depression. But side effects are many, so they measured the Likelihood to be Helped or Harmed in several categories of side effects:
Weight gain, EPS, fatigue, akathisia, nausea, and drop out due to any adverse effect.
I should note the study was sponsored by Sunovion, the maker of lurasidone. But I have reviewed the data in other less biased sources and agree with the general consensus there. Lurasidone is one of the better tolerated antipsychotics, and with a number needed to treat of 5 it stands comfortably alongside OFC and quetiapene ─ those two are high on efficacy but lower on tolerability.
OFC – olanzapine fluoxetine combination ─ was actually a close second to lurasidone in most category except weight gain. Quetiapine, on the other hand, sank to the bottom in most categories. Although Quetiapine ranks high for both short- and long-term efficacy in bipolar disorder mania and depression, it’s also the atypical that patients are most quit in the short term, and its side effects like fatigue and hypotension are the reason.
What about cariprazine/Vraylar? It’s basically the less effective cousin of lurasidone.

Lemborexant/Dayvigo is the second in sleep med to join the orexin receptor antagonist family. It’s now on the pharmacy shelves, where it sits beside Suvorexant/Bellsomra, released in 2015. Landry I, Nakai K, Ferry J, et al. Pharmacokinetics, pharmacodynamics, and safety of the dual orexin receptor antagonist lemborexant: Findings from single-dose and multiple-ascending-dose phase 1 studies in healthy adults. Clin Pharmacol Drug Dev. 2020;10.1002/cpdd.817. [Link (https://pubmed.ncbi.nlm.nih.gov/32468649/)]
Published Today: 6/27/20
Duration: 1 minute, 49 seconds
Transcript:
Lemborexant/Dayvigo is the second in sleep med to join the orexin receptor antagonist family. It’s now on the pharmacy shelves, where it sits beside Suvorexant/Bellsomra, released in 2015. Today, we review its pharmacokinetics from a new industry-sponsored meta-analysis of 3 RCTs by Ishani Landry:
Lemborexant reaches its peak in 1-3 hours. Tell patients to take it right before going to bed.
Its half life is 17-19 hours, 30% of the drug is still in the bloodstream the next morning, but this didn’t seem to cause any next-day functional effects. Patients should allow at least 7 hours of sleep when they take lemborexant. One advantage of the orexin class is that they are better studied ─ and have better safety metrics ─ in the elderly than the z-hypnotics.
Start lemborexant at 5 mg/night and titrated as needed to a max of 10 mg/night. Watch out for drug interactions with CYP3A inhibitors and inducers. Strong CYP3A inhibitors like nefazodone and HIV meds can increase it 4-fold, while moderate ones like the calcium channel blockers increase it about 1.5 fold.
The analysis included a Japanese study, but race did not seem to effect lemborexant‘s pharmacokinetics
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