FOCUS POINTS 1 Venlafaxine, milnacipran, and duloxetine block the reuptake of serotonin (5-HT) and norepinephrine (NE) with differing selectivity. Approximate potency ratios (5-HT:NE) are 1:1 for milnacipran, 1:10 for duloxetine, and 1:30 for venlafaxine.• When used at doses that cause inhibition of the reuptake of both 5-HT and NE, treatment with all three serotonin and norepinephrine reuptake inhibitors (SNRIs) produce higher rates of response and remission from major depression than the selective serotonin reuptake inhibitors (SSRIs). 1 SNRIs are effective in treating a variety of anxiety disorders. Efficacy of SNRIs and SSRIs in anxiety is comparable. 1 SNRIs are effective in the treatment of chronic pain, whereas SSRIs are generally not useful. ' Venlafaxine seems t o be the least well-tolerated SNRI, combining a high level of serotonergic adverse effects (nausea, sexual dysfunction, w i t h d r a w a l problems) with dose-dependent hypertension. In contrast, duloxetine and milnacipran appear better tolerated and essentially devoid of cardiovascular toxicity. ABSTRACT The class of serotonin and norepinephrine reuptake inhibitors (SNRIs) now comprises three medications: venlafaydne, milnacipran, and duloxetine. These drugs block the reuptake of both serotonin (5-HT) and norepineph-rine with differing selectivity. Whereas milnacipran blocks 5-HT and norepinephrine reuptake with equal affinity, duloxetine has a 10-fold selectivity for 5-HT and venlafaxine a 30-fold selectivity for 5-HT. M three SNRIs are efficacious in treating a variety of anxiety disorders. There is no evidence for major differences between SNRIs and SSRIs in their efficacy in treating anxiety disorders. In contrast to SSRIs, which are generally ineffective in treating chronic pain, all three SNRIs seem to be helpful in relieving chronic pain associated with and independent of depression. Tolerability of an SNRI at therapeutic doses varies within the class. Although no direct comparative data are available, venlafaxine seems to be the least well-tolerated, combining serotonergic adverse effects (nausea, sexual dysfunction, withdrawal problems) with a dose-dependent cardiovascular phenomenon, principally hypertension. Duloxetine and milnacipran appear better tolerated and essentially devoid of cardiovascular toxicity.* Positive numbers: more selective uptake inhibition and binding for NE transporter than 5-HT transporter. Negative numbers: more selective for 5-HT transporter than NE transporter. Adapted with permission from the Journal of Clinical Psychiatry. Owens MJ. Selectivity of antidepressants: from the monoamine hypothesis of depression to the SSRI revolution and beyond. * Taken from a meta-analysis comparing milnacipran 100 mg/day (n=1,871) and SSRIs. 43 * 4 t Taken from a pooled analysis of venlafaxine (IR and XR) used at variable doses from 75-225 mg/day (n=851) and SSRIs (n=748). 45p46 t Taken from a comparative study of duloxetine 40 mg/day (data not shown) and 80 mg/day (n=91) and paroxetine 20 mg/day (n=87). 47 § Response rate is...

Despite the fact that monoamine oxidase inhibitors (MAOIs) can be highly effective therapeutic agents for depression and some anxiety disorders, they tend to be underutilized in clinical practice. This is due at least in part to the fact that there is a great deal of misinformation and mythology about their dietary and drug interactions. This article is intended to serve as a guide for clinicians who are not particularly familiar with MAO inhibitors; its aim is to help these clinicians competently integrate these agents into clinical practice when appropriate.

Restricting polypharmacy may reduce costs and prevent the need for prior-authorization restrictions.

All of the titles in the Stahl's Illustrated series are designed to be fun. Concepts are illustrated by full-color images that will be familiar to readers of Stahl's Essential Psychopharmacology, 3rd edition, and The Prescriber's Guide. The visual learner will find that these books make psychopharmacology concepts easy to master, while the non-visual learner will enjoy a shortened text version of complex psychopharmacology concepts. Each chapter builds on previous ones, synthesizing information from basic biology and diagnostics to building treatment plans and dealing with complications and comorbidities. Novices may want to begin by looking through all the graphics and gaining a feel for the visual vocabulary. Readers more familiar with these topics should find that going back and forth between images and text provides an interaction with which to vividly conceptualize complex pharmacologies. Each book ends with a Suggested Reading section to help guide more in-depth learning about particular concepts.

Medical education often presents new material as large data dumps at a single live event (lecture or symposium), in part because it is traditional, and also because this structure can be perceived as the most time efficient for busy clinicians and their teachers. However, modern learning theory and new insights from the neurobiological basis of long-term memory formation show that the format of single-event presentation of materials is not very effective. Rather, seeing the presentation of new materials over time, in bite-sized chunks, and then seeing them again at a later time, particularly as a test, leads to more retention of information than does learning the same amount of material as a large bolus in a single setting. This notion of learning over time, also called “interval learning” or “spaced learning,” is particularly well adapted to the Internet era. Here we describe an application of this concept to the learning of psychopharmacology over time in bite-sized and repeated portions structured as an “online fellowship” called the Master Psychopharmacology Program (www.neiglobal.com/mpptour).