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style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="cognitive impairment" title="cognitive impairment" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:cover"/><noscript><img alt="cognitive impairment" title="cognitive impairment" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F5476754e757653879d3480325a03757be0d9d866-6250x3125.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F5476754e757653879d3480325a03757be0d9d866-6250x3125.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F5476754e757653879d3480325a03757be0d9d866-6250x3125.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:cover" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/addressing-sleep-disturbances-associated-with-cognitive-impairment">Addressing Sleep Disturbances Associated With Cognitive Impairment</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/leah-kuntz">Leah Kuntz</a></span></div><p class="text-sm text-gray-500">November 4th 2024</p><p class="text-md block">A new collaboration to address sleep disturbances associated with cognitive impairment, an unmet need. </p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/effects-of-noninvasive-neurostimulation-on-sleep-quality-and-symptoms-in-depression"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="depressed sleep" title="depressed sleep" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="depressed sleep" title="depressed sleep" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe2728bd58e94141266152f4f7e8b9cbd04c60a7d-4726x3150.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe2728bd58e94141266152f4f7e8b9cbd04c60a7d-4726x3150.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fe2728bd58e94141266152f4f7e8b9cbd04c60a7d-4726x3150.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/effects-of-noninvasive-neurostimulation-on-sleep-quality-and-symptoms-in-depression">Effects of Noninvasive Neurostimulation on Sleep Quality and Symptoms in Depression</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/brian-miller-md-phd-mph">Brian Miller, MD, PhD, MPH</a></span></div><p class="text-sm text-gray-500">September 6th 2024</p><p class="text-md hidden">Will this help my sleep and mood? Researchers investigated the effects of noninvasive neurostimulation on sleep quality and depressive symptoms in patients with major depressive disorder in a meta-analysis of randomized controlled trials.</p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/insomnia-and-the-antisuicidal-properties-of-clozapine"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="insomnia" title="insomnia" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="insomnia" title="insomnia" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fb6a6f7d01f3c0d8f5d903867c15ef258a45221c2-5600x3737.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fb6a6f7d01f3c0d8f5d903867c15ef258a45221c2-5600x3737.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fb6a6f7d01f3c0d8f5d903867c15ef258a45221c2-5600x3737.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/insomnia-and-the-antisuicidal-properties-of-clozapine">Insomnia and the Antisuicidal Properties of Clozapine </a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/brian-miller-md-phd-mph">Brian Miller, MD, PhD, MPH</a></span></div><p class="text-sm text-gray-500">August 30th 2024</p><p class="text-md hidden">Sleep and suicide? Researchers investigated improvement in insomnia as a pathway underlying the antisuicidal properties of clozapine.</p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/approved-snda-wakix-for-treatment-of-excessive-daytime-sleepiness-in-youth-with-narcolepsy"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="sleepy child" title="sleepy child" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="sleepy child" title="sleepy child" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F76a414ec9e88d24236b399ce198fdc37bc50f866-6852x4569.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F76a414ec9e88d24236b399ce198fdc37bc50f866-6852x4569.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F76a414ec9e88d24236b399ce198fdc37bc50f866-6852x4569.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/approved-snda-wakix-for-treatment-of-excessive-daytime-sleepiness-in-youth-with-narcolepsy">Approved sNDA: Wakix for Treatment of Excessive Daytime Sleepiness in Youth With Narcolepsy</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/leah-kuntz">Leah Kuntz</a></span></div><p class="text-sm text-gray-500">June 24th 2024</p><p class="text-md hidden">The FDA has approved its supplemental New Drug Application for Wakix tablets for the treatment of excessive daytime sleepiness in pediatric patients aged 6 years and older with narcolepsy. </p></div></div><div class="grid grid-cols-4 gap-3 mt-3 "><a href="/view/the-week-in-review-june-17-21"><div class="w-full aspect-square overflow-hidden rounded-bl-[10%]"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27250%27%20height=%27250%27/%3e"/></span><img alt="Here are highlights from the week in Psychiatric Times." title="Here are highlights from the week in Psychiatric Times." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" class="object-cover w-full h-full" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:"/><noscript><img alt="Here are highlights from the week in Psychiatric Times." title="Here are highlights from the week in Psychiatric Times." srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F5e8798690ca96ea1f5db8838133c1aa80958230f-800x533.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F5e8798690ca96ea1f5db8838133c1aa80958230f-800x533.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F5e8798690ca96ea1f5db8838133c1aa80958230f-800x533.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:" class="object-cover w-full h-full" loading="lazy"/></noscript></span></div></a><div class="col-span-3 space-y-1"><a class="font-bold text-md md:text-lg" href="/view/the-week-in-review-june-17-21">The Week in Review: June 17-21</a><div><span class="text-md "><span class="mr-1 italic">By </span><a class="mr-1 text-sky-800 hover:text-primary" href="/authors/erin-o-brien">Erin O'Brien</a></span></div><p class="text-sm text-gray-500">June 22nd 2024</p><p class="text-md hidden">Here are highlights from the week in Psychiatric Times.</p></div></div></div></div><div class="jsx-19ede9f0a5a45918 py-4 relative px-0"><div class="jsx-19ede9f0a5a45918 "><div class="flex justify-between items-center py-1 space-x-4 border-0 select-none sm:border-b border-secondary"><div class="text-3xl text-primary ">Video Interviews</div></div></div><div style="scroll-snap-type:none" class="jsx-19ede9f0a5a45918 flex items-start overflow-x-auto space-x-4 py-4 relative mx-auto w-[calc(100%-64px)]"><a id="" class="w-[200px] h-fit space-y-3 flex-none select-none no-underline" style="scroll-snap-align:center;text-decoration:none" href="/view/clinical-pearls-for-the-management-of-patients-suffering-from-narcolepsy"><div class="w-full shadow-md shadow-gray-800 overflow-hidden relative bg-white aspect-video"><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:absolute;top:0;left:0;bottom:0;right:0"><img alt="" title="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="fill" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" title="" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6395a4e90ef6b7a8f8a58ade832e68602edc1841-1920x1080.png%2Fmarketing%2520image%2520(45).png%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=30 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6395a4e90ef6b7a8f8a58ade832e68602edc1841-1920x1080.png%2Fmarketing%2520image%2520(45).png%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=30 750w, 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mt-4 font-light no-underline text-gray-700"></div></a><a id="" class="w-[200px] h-fit space-y-3 flex-none select-none no-underline" style="scroll-snap-align:center;text-decoration:none" href="/view/non-pharmacologic-interventions-for-pediatric-patients-with-narcolepsy"><div class="w-full shadow-md shadow-gray-800 overflow-hidden relative bg-white aspect-video"><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:absolute;top:0;left:0;bottom:0;right:0"><img alt="" title="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="fill" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" title="" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6395a4e90ef6b7a8f8a58ade832e68602edc1841-1920x1080.png%2Fmarketing%2520image%2520(45).png%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=30 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6395a4e90ef6b7a8f8a58ade832e68602edc1841-1920x1080.png%2Fmarketing%2520image%2520(45).png%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=30 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6395a4e90ef6b7a8f8a58ade832e68602edc1841-1920x1080.png%2Fmarketing%2520image%2520(45).png%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=30 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6395a4e90ef6b7a8f8a58ade832e68602edc1841-1920x1080.png%2Fmarketing%2520image%2520(45).png%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=30 1080w, 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src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6395a4e90ef6b7a8f8a58ade832e68602edc1841-1920x1080.png%2Fmarketing%2520image%2520(45).png%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=30" decoding="async" data-nimg="fill" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span></div><div class="w-full flex-wrap text-center text-sm mt-4 font-light no-underline text-gray-700"></div></a><a id="" class="w-[200px] h-fit space-y-3 flex-none select-none no-underline" style="scroll-snap-align:center;text-decoration:none" href="/view/considerations-for-the-management-of-pediatric-patients-with-narcolepsy"><div class="w-full shadow-md shadow-gray-800 overflow-hidden relative bg-white aspect-video"><span 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Kuntz</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/andrew-krystal-md">Andrew Krystal, MD</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/wayne-drevets-md">Wayne Drevets, MD</a></div><a href="/view/seltorexant-major-depressive-disorder-and-insomnia-thoughts-on-the-new-data"><span class="text-sm text-gray-500 pl-4">June 6th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Andrew Krystal, MD, and Wayne Drevets, MD, share their thoughts on the recent seltorexant data presented at the 2024 ASCP Annual Meeting. </p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/seltorexant-major-depressive-disorder-and-insomnia-thoughts-on-the-new-data"><p class="font-bold text-[.75rem]">Read More</p></a><div 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href="/authors/stefanie-n-howell-phd">Stefanie N. Howell, PhD</a></div><a href="/view/neuroplasticity-after-brain-injury-principles-and-methods-for-postinjury-improvement"><span class="text-sm text-gray-500 pl-4">May 29th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Improving cognitive function is a primary goal of brain injury rehabilitation and is made possible through the process of neuroplasticity.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/neuroplasticity-after-brain-injury-principles-and-methods-for-postinjury-improvement"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div 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/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F99ce5f2fb31ffcf31f21371786698d2137e166df-5068x3379.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F99ce5f2fb31ffcf31f21371786698d2137e166df-5068x3379.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/the-2024-apa-annual-meeting-tuesday-may-7">The 2024 APA Annual Meeting: Tuesday, May 7</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/the-2024-apa-annual-meeting-tuesday-may-7"><span class="text-sm text-gray-500 pl-4">May 8th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Here are highlights from the fourth day of this year’s APA Annual Meeting.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/the-2024-apa-annual-meeting-tuesday-may-7"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="flex md:hidden justify-center items-center"></div><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/from-the-pages-of-psychiatric-times-april-2024"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:130.70866141732282%"></span><img alt="The experts weighed in on a wide variety of psychiatric issues for the April issue of Psychiatric Times." title="The experts weighed in on a wide variety of psychiatric issues for the April issue of Psychiatric Times." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="The experts weighed in on a wide variety of psychiatric issues for the April issue of Psychiatric Times." title="The experts weighed in on a wide variety of psychiatric issues for the April issue of Psychiatric Times." sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F4dbfc8d2113c0a71966d4f6bdb1345b571dd5e49-1016x1328.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, 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w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/from-the-pages-of-psychiatric-times-april-2024">From the Pages of Psychiatric Times: April 2024</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/from-the-pages-of-psychiatric-times-april-2024"><span class="text-sm text-gray-500 pl-4">April 27th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">The experts weighed in on a wide variety of psychiatric issues for the April issue of Psychiatric Times.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/from-the-pages-of-psychiatric-times-april-2024"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/assessing-and-treating-insomnia-in-older-adults"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:66.66666666666666%"></span><img alt="insomnia" title="insomnia" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="insomnia" title="insomnia" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1920&q=75 1920w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=2048&q=75 2048w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6a0147bffe5d17786ee8c5c3afadd3a982747b90-6720x4480.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/assessing-and-treating-insomnia-in-older-adults">Assessing and Treating Insomnia in Older Adults</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/rajesh-r-tampi-md-ms-dfapa-dfaagp">Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP</a></div><a href="/view/assessing-and-treating-insomnia-in-older-adults"><span class="text-sm text-gray-500 pl-4">April 26th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">In this CME article, discuss and describe the epidemiology, assessment, and evidence-based treatment of insomnia in older adults. </p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/assessing-and-treating-insomnia-in-older-adults"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/the-role-of-orexin-receptor-2-agonists-in-sleep-and-narcolepsy-type-1"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:66.66666666666666%"></span><img alt="narcolepsy" title="narcolepsy" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="narcolepsy" title="narcolepsy" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1920&q=75 1920w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=2048&q=75 2048w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F04a2e0c533d28b7a18ff791c81d0007f7ba2fb5e-5760x3840.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/the-role-of-orexin-receptor-2-agonists-in-sleep-and-narcolepsy-type-1">The Role of Orexin Receptor 2 Agonists in Sleep and Narcolepsy Type 1 </a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/leah-kuntz">Leah Kuntz</a><span class="mr-1 ml-[1px]">;</span><a class="text-sm text-sky-800" href="/authors/elena-koundourakis">Elena Koundourakis</a></div><a href="/view/the-role-of-orexin-receptor-2-agonists-in-sleep-and-narcolepsy-type-1"><span class="text-sm text-gray-500 pl-4">February 15th 2024</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Elena Koundourakis, the head of the Orexin Franchise Development and Portfolio Strategy at Takeda, shares her thoughts on the recent positive topline results from a phase 2 trial evaluating TAK-861, an oral orexin receptor 2 agonist, in patients with narcolepsy type 1. </p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/the-role-of-orexin-receptor-2-agonists-in-sleep-and-narcolepsy-type-1"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/positive-data-on-oral-orexin-receptor-2-agonist-for-patients-with-narcolepsy-type-1"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span 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mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/objectively-measured-sleep-in-adhd"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:66.66666666666666%"></span><img alt="What is the impact of ADHD on sleep? Researchers performed a systematic review and meta-analysis of objectively measured sleep in children and adolescents with ADHD." title="What is the impact of ADHD on sleep? Researchers performed a systematic review and meta-analysis of objectively measured sleep in children and adolescents with ADHD." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="What is the impact of ADHD on sleep? 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Researchers performed a systematic review and meta-analysis of objectively measured sleep in children and adolescents with ADHD.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/objectively-measured-sleep-in-adhd"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/gabapentinoids-a-deeper-look"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:54.13322632423756%"></span><img alt=""During the past 5 years has gabapentin retained its position as one of the top 10 drugs prescribed in the United States."" title=""During the past 5 years has gabapentin retained its position as one of the top 10 drugs prescribed in the United States."" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt=""During the past 5 years has gabapentin retained its position as one of the top 10 drugs prescribed in the United States."" title=""During the past 5 years has gabapentin retained its position as one of the top 10 drugs prescribed in the United States."" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1920&q=75 1920w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=2048&q=75 2048w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 3840w" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fffc83b979e199801f075e9a5bb388d8f878cc1ef-4984x2698.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/gabapentinoids-a-deeper-look">Gabapentinoids: A Deeper Look</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/john-j-miller-md">John J. Miller, MD</a></div><a href="/view/gabapentinoids-a-deeper-look"><span class="text-sm text-gray-500 pl-4">November 9th 2023</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">"During the past 5 years has gabapentin retained its position as one of the top 10 drugs prescribed in the United States."</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/gabapentinoids-a-deeper-look"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/the-week-in-review-october-30-november-3"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:54.93333333333334%"></span><img alt="From sleep and neuroendocrine function following TBI to new phase 3 results from a clinical trial evaluating a promising new schizophrenia treatment, here are highlights from the week in Psychiatric Times." title="From sleep and neuroendocrine function following TBI to new phase 3 results from a clinical trial evaluating a promising new schizophrenia treatment, here are highlights from the week in Psychiatric Times." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="From sleep and neuroendocrine function following TBI to new phase 3 results from a clinical trial evaluating a promising new schizophrenia treatment, here are highlights from the week in Psychiatric Times." title="From sleep and neuroendocrine function following TBI to new phase 3 results from a clinical trial evaluating a promising new schizophrenia treatment, here are highlights from the week in Psychiatric Times." sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1080&q=75 1080w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F51d3cd8b64698f18bbaa58a4dd6d2804957c12c0-1500x824.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=1200&q=75 1200w, 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style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/the-week-in-review-october-30-november-3">The Week in Review: October 30-November 3</a></p><div class=" pl-4"><a class="text-sm text-sky-800" href="/authors/erin-o-brien">Erin O'Brien</a></div><a href="/view/the-week-in-review-october-30-november-3"><span class="text-sm text-gray-500 pl-4">November 4th 2023</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">From sleep and neuroendocrine function following TBI to new phase 3 results from a clinical trial evaluating a promising new schizophrenia treatment, here are highlights from the week in Psychiatric Times.</p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/the-week-in-review-october-30-november-3"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col md:items-center lg:items-start lg:flex-row mb-4 mt-3 "><div class="flex flex-1 md:col-span-2 " style="background-color:transparent;border-color:#F3F4F6;border-width:0;border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem"><a class=" md:flex-none w-full md:w-48 mt-2" href="/view/recognize-address-bidirectional-relationship-sleep-neuroendocrine-function-improve-tbi-outcomes"><div class=""><span style="box-sizing:border-box;display:block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;padding-top:66.73913043478261%"></span><img alt="sleep" title="sleep" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="responsive" class="shrink-0" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%"/><noscript><img alt="sleep" title="sleep" sizes="100vw" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc171dc480f74d4e37e67ed288433354b777c9fc1-7360x4912.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=640&q=75 640w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc171dc480f74d4e37e67ed288433354b777c9fc1-7360x4912.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=750&q=75 750w, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc171dc480f74d4e37e67ed288433354b777c9fc1-7360x4912.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=828&q=75 828w, 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src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc171dc480f74d4e37e67ed288433354b777c9fc1-7360x4912.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="responsive" style="border-top-left-radius:0rem;border-top-right-radius:0rem;border-bottom-left-radius:0rem;border-bottom-right-radius:0rem;position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%" class="shrink-0" loading="lazy"/></noscript></span></div></a><div class="flex-auto w-[200%] md:w-auto ml-2 flex-1"><p class="font-bold text-[1rem] pl-4 text-undefined" style="font-size:1rem"><a href="/view/recognize-address-bidirectional-relationship-sleep-neuroendocrine-function-improve-tbi-outcomes">Recognize and Address the Bidirectional Relationship Between Sleep and Neuroendocrine Function to Improve TBI Outcomes</a></p><div class=" pl-4"><a 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Howell, PhD</a></div><a href="/view/recognize-address-bidirectional-relationship-sleep-neuroendocrine-function-improve-tbi-outcomes"><span class="text-sm text-gray-500 pl-4">October 31st 2023</span><div class="mt-2 ml-4"></div><div class="flex flex-row gap-2"></div><p class=" mt-4 text-gray-800 pl-4">Sleep and neuroendocrine function are disrupted following TBI. </p><div class="pl-4"></div></a><a class="flex items-center justify-center w-24 h-8 mt-4 ml-4 bg-primary border border-primary text-white hover:text-primary hover:bg-white hover:border-primary" href="/view/recognize-address-bidirectional-relationship-sleep-neuroendocrine-function-improve-tbi-outcomes"><p class="font-bold text-[.75rem]">Read More</p></a><div class="flex flex-col sm:flex-row pl-2 mt-4"></div></div></div></div></div></div><div class="w-full h-full"><hr class="mt-1 w-full " style="border-top-width:1px;border-top-color:#F3F4F6"/><div class="w-full h-full"><div class="w-full md:w-auto md:flex md:flex-col 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I think the take-home message there is that we do have lots of choices, they have different delivery processes, and different mechanisms of action, and polypharmacy is, quite frankly, not uncommon."}],"_type":"block"},{"style":"normal","_key":"85d51809e456","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"c0c1d19307330"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"65ced09730350"},{"_type":"span","marks":[],"text":": It’s rare that you get away with just monotherapy in this patient population, unfortunately.","_key":"65ced09730351"}],"_type":"block","style":"normal","_key":"15438b240f99"},{"_key":"3844e0bfbbf6","markDefs":[],"children":[{"text":"","_key":"5967898718080","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_key":"5c31644f48f0","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Richard K. 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Do you have any other takeaways or points you want to make here, in terms of these individuals, and how we approach them and diagnose them?","_key":"8e4ee6525c331","_type":"span"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"38e5a4819df4","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"fd4a37fdc3d70"}]},{"_type":"block","style":"normal","_key":"77887d872908","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"3e10bb4a0a050"},{"_key":"3e10bb4a0a051","_type":"span","marks":[],"text":": I think it’s just paying attention to these symptoms, not discounting or lumping them under 1 disease that you’re trying to put everything into 1 diagnosis, which is ideal, but many of these patients have more than one thing going on. It’s important to keep a broad mind, a broad approach. Again, I think it’s important to find these patients, the earlier, the better in terms of changing their trajectory in life. Because we’re seeing patients in their 30s and 40s, and they could have been in a different place in their career and their path in terms of their family members and all that if they knew what was going on at an earlier age."}]},{"style":"normal","_key":"8dd1b8367b77","markDefs":[],"children":[{"text":"","_key":"6fec9fd80bdd0","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"e00eb1d86065","markDefs":[],"children":[{"text":"Richard K. Bogan, MD, FCCP, FAASM: ","_key":"a1a4543400f70","_type":"span","marks":["strong"]},{"text":"Exactly. I think when a clinician sees a tired patient, who has executive function abnormality, attention, memory, etc, perhaps has mood changes, depression, or anxiety, I think we need to ask them, are they sleepy? And it’s fairly easy to do an Epworth Sleepiness Scale score. And if you find they are sleepy, there’s a reason why they are sleepy. And if you make the sleepiness better, then those other things will get better. The fatigue, the attention problems, executive function, mood, all those things will get better. Quite frankly, if we do that, I think we’ll identify more of these individuals earlier because of these pretty remarkable symptoms, but we first have to figure out if they’re sleepy.","_key":"a1a4543400f71","_type":"span","marks":[]}],"_type":"block"},{"_type":"block","style":"normal","_key":"f5e5bb1eddd5","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"afd4606565320"}]},{"style":"normal","_key":"c93e47d33938","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Asim, this has been a great conversation. I really appreciate it. I hope the clinicians listening in also appreciate it. This has been very valuable to me. Thank you very much.","_key":"83bb70a9b3870"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"4a66877fbb9e0"}],"_type":"block","style":"normal","_key":"ed83357add30"},{"_type":"block","style":"normal","_key":"9319d98c692e","markDefs":[],"children":[{"marks":["strong"],"text":"Asim Roy, MD","_key":"da2cad9ff8bf0","_type":"span"},{"text":": Thank you. Always enjoyable.","_key":"da2cad9ff8bf1","_type":"span","marks":[]}]},{"_key":"37ea27579fd5","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript Edited for Clarity","_key":"57c23e916ae1"}],"_type":"block","style":"normal"}],"_updatedAt":"2023-04-26T15:43:52Z","is_visible":true,"internalTag":["practice pearls","narcolepsy"],"link":"/view/practice-pearls-for-narcolepsy-management","factCheckAuthorMapping":null,"documentGroupMapping":[{"_ref":"6d118f7b-44de-4ff5-bc51-283e88e9d7c4","_type":"reference","_key":"fa95d64766d0"}],"summary":"Richard K. 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Bogan, MD, FCCP, FAASM: "},{"marks":[],"text":"I’m going to throw another case at you. We’ve got a 29-year-old male project manager who presents with excessive sleepiness. He also has vivid dreams and episodes of awakening in the night feeling as though he is paralyzed and can’t move. He feels short of breath and panics during that. His bed partner says he talks a lot, kicks and yells, and sometimes when he wakes up, he sees these images or hears somebody outside trying to break into the house. He is diagnosed with having adult ADD [attention-deficit disorder] and is placed on extended-release methylphenidate, which helped his sleepiness, interestingly enough, but he is still aggravated by the sleepiness. He can still doze off in the afternoon and has trouble with projects during the day, dozing off when he is not adequately stimulated.","_key":"37f36e515aca1","_type":"span"}],"_type":"block","style":"normal","_key":"54ec4ebdbafc","markDefs":[]},{"_key":"e4f67c5f261e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"146998b5aea90"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"d01ce2bbd25d","markDefs":[],"children":[{"_type":"span","marks":[],"text":"His clinical course has been somewhat problematic because he does have anxiety, some performance anxiety, and the methylphenidate makes his heart rate go up and makes him more nervous. He has not had any episodes of muscle weakness with strong emotions. He’s diagnosed with having an anxiety disorder and placed on escitalopram. His BMI [body mass index] is 32, and his blood pressure is 129 over 89 mm Hg, so his blood pressure is a little high. His heart rate is 78 bpm. He is actually on metoprolol for tachycardia and anxiety. So we have a fellow who is a little overweight, with elevated blood pressure and an anxiety disorder, with those symptoms. I will go ahead and tell you his MSLT [Multiple Sleep Latency Test result] was 6 minutes, and he only had 1 sleep onset REM episode. What do you think?","_key":"8703e0aa2d0d0"}]},{"style":"normal","_key":"bae945e27c03","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"13e7527065fb0"}],"_type":"block"},{"_type":"block","style":"normal","_key":"415a967ed2e7","markDefs":[],"children":[{"marks":["strong"],"text":"Asim Roy, MD","_key":"eee8b180823b0","_type":"span"},{"_type":"span","marks":[],"text":": There’s another REM dissociation we didn’t get into, which I forgot to mention, but REM behavior disorder might be a feature in narcolepsy as well, where people act out their dreams. Normally, we think about this in individuals in their 50s, 60s, and 70s if they develop REM behavior. It’s a whole different meaning, potential neurodegenerative disease implications with a synucleinopathy world like Parkinson disease or Parkinson-like syndromes. In narcolepsy though, you can have REM behavior disorder at a younger age, and it can be part of that REM phenomena. There was some description of that, it seemed like, potentially; we need to dive deeper. But for me, the PSG [polysomnography], I don’t think there was any mention of the results on the PSG on this case?","_key":"eee8b180823b1"}]},{"_type":"block","style":"normal","_key":"9d78a2955f5a","markDefs":[],"children":[{"_key":"6caed881b4b10","_type":"span","marks":[],"text":""}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: ","_key":"3f74337004d30"},{"_type":"span","marks":[],"text":"He did have a bit of mild sleep apnea, with an AHI [apnea-hypopnea index score] of 6, and he had mild intermittent snoring.","_key":"3f74337004d31"}],"_type":"block","style":"normal","_key":"51fd64a06bb4"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"1c4ab6426f5a0"},{"_type":"span","marks":[],"text":": He had mild sleep apnea, I don’t think that by itself explains the degree of sleepiness. Again, you can have REM dissociation, REM-related phenomenon with sleep apnea in normal individuals as well. But again, the profoundness of how often it’s happening and how intense they are, it’s hard for me to blame it on a mild degree of sleep apnea, but it’s possible. And then that 1 SOREMP [sleep onset REM period], to me, again, he’s on an antidepressant, and I’m assuming it was left on board during the test. That may have suppressed a second REM phenomenon, a SOREMP, potentially. But putting it all together, I still have a high suspicion there’s probably type 2 narcolepsy going on with underlying mild sleep apnea. In scenarios like this, he may have some blood pressure issues. He’s on metoprolol, so it might be suppressing his blood pressure already, and that’s slightly elevated.","_key":"1c4ab6426f5a1"}],"_type":"block","style":"normal","_key":"2b20f2dac0ee"},{"_type":"block","style":"normal","_key":"0f82945d282e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"b045f56c59d90"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"I would lean toward treating his mild sleep apnea, whether it’s PAP [positive airway pressure] therapy or an oral appliance to manage that component. But my suspicion is his persistent sleepiness, those persistent REM phenomena, may not disappear just by treating the OSA [obstructive sleep apnea]. Then at that point, I would feel more confident saying this is most likely a type 2 narcolepsy and then tackling those REM-related phenomena that are disturbing to him.","_key":"8f19314246c10"}],"_type":"block","style":"normal","_key":"04f9c8c7329c"},{"_type":"block","style":"normal","_key":"e521e7f25f28","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"12ac0a3001cd0"}]},{"children":[{"_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: ","_key":"3cd21ac83e8a0"},{"_type":"span","marks":[],"text":"I think that’s a good point. With the escitalopram, we may have to call the psychiatrist or family practitioner and say, “Hey.” And I’d talk to the patient as well, “Is there any chance we can take this patient off this medicine?” They’ll have to be off of it for a while, probably at least 2 weeks, fluoxetine much longer, but at least 2 weeks before we do the study. Because…we don’t fully know, but there are enough observational data that suggest this is suppressing REM sleep and will affect our nap studies. So that 1 SOREMP may have been distorted by that. Asim, what do you think about solriamfetol in this case?","_key":"3cd21ac83e8a1"}],"_type":"block","style":"normal","_key":"2970a389972e","markDefs":[]},{"style":"normal","_key":"c60619609c02","markDefs":[],"children":[{"marks":[],"text":"","_key":"ba1a4073e9ca0","_type":"span"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"1dbcbe6939b90"},{"_key":"1dbcbe6939b91","_type":"span","marks":[],"text":": I think it definitely has value. He’s on a stimulant, he’s seen some benefit. But could we have a little more enhanced benefit with a nonstimulant option because of his concerns with blood pressure, tachycardia, and anxiety? There are many reasons why we should probably try to get him off the stimulant if we can. With solriamfetol, the data support that there might be very little if any heart rate or blood pressure effect. Then you can get the weight-promoting benefits without having those downstream adverse effects. I think anxiety was only seen in less than 2% or 3% of the cases, using solriamfetol. So again, it’s still possible to have those downstream adverse effects, but the probability is significantly less than the traditional stimulants. I think solriamfetol would be a great option for him…from a cardiovascular standpoint, the anxiety standpoint, and the sustained benefit of something that can last 9 or 10 or so hours. He’s a project manager, and keeping him awake throughout the day can be challenging I would imagine, so replacing the stimulant with solriamfetol, I think would have added value there."}],"_type":"block","style":"normal","_key":"bb6280540f5c"},{"_key":"e51a1d835f6a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"173bf052c04f0"}],"_type":"block","style":"normal"},{"_key":"cfcc86c1dd0f","markDefs":[],"children":[{"text":"Richard K. Bogan, MD, FCCP, FAASM: ","_key":"2dfbc1f608d30","_type":"span","marks":["strong"]},{"_key":"2dfbc1f608d31","_type":"span","marks":[],"text":"I would agree. I think in situations where we have all of this anxiety and tachycardia and issues, blood pressure, we’re going to move more obviously toward the modafinil, armodafinil, and of course the solriamfetol. Then again, thinking about drug-drug interaction and some of those things. Let’s go back to our first case of the young girl with type 1, and we put her on oxybate therapy. I’ve treated her, so she was placed on low oxybate therapy and had significant improvement in the sleep disruption and the vivid dreams paralysis, and the cataplexy. But she was still sleepy, and she was pretty insistent on taking oral contraceptives, steroidal oral contraceptives. What do we do there?"}],"_type":"block","style":"normal"},{"_key":"07c1c516c7cf","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"98d447fc82810"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"a5922b9616c00"},{"_type":"span","marks":[],"text":": That’s a great point. As you know, modafinil and armodafinil have a drug-drug interaction. Pitolisant has that drug-drug interaction. So if we decide to go down that road, those are significant counseling discussions with the patient. Again, solriamfetol definitely has a role here in the sense that it does not have that drug-drug interaction, it’s renally metabolized, does not go through any of the cytochrome P systems. It would be the ideal option to allow her to continue the oral contraceptives, supplement the oxybate at night, and get her through the day a bit better; it would be my first choice. 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","body":[{"_type":"video","videoID":"6326189697112","disableAutoPlayVideo":false,"source":"brightcove","_key":"5d432a3e5ce0","videoObject":{"_type":"videoDetails","videoTitle":"Managing Ambient Light and Temperature for Restful Sleep","thumbnail":{"asset":{"_type":"reference","_ref":"image-83df0fec9a9a561a4023987d5297528616470e51-1280x706-png"},"_type":"image"},"videoDuration":"7 minutes","videoDescription":"Managing Ambient Light and Temperature for Restful Sleep"}},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Susan J. Noonan, MD, MPH, talks about how to best create a sleep-friendly environment for your patient. ","_key":"b0b8eaebd536"}],"_type":"block","style":"normal","_key":"6f7e5ac912cc"},{"_type":"block","style":"normal","_key":"b33546f27d79","markDefs":[],"children":[{"text":"Dr Noonan","_key":"3db669ca3e6c0","_type":"span","marks":["strong"]},{"_key":"3db669ca3e6c1","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["em"],"text":"is a physician, mental health and wellness coach; author of 5 books on managing mental health and mood disorders with a print and video blog; consultant; group facilitator; and Certified Peer Specialist. She has a unique perspective having lived with a mood disorder and bridges that space between provider and recipient of mental health services, which resonates with many people. Dr Noonan is the inaugural recipient of the national Depression and Bipolar Support Alliance Peer Support Specialist of the Year 2022. 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Bogan, MD, FCCP, FAASM","_createdAt":"2020-09-24T13:36:06Z","_type":"author","url":{"_type":"slug","current":"richard-bogan-md"},"lastName":"Bogan","_rev":"VK3VX4M8foqKA88p8UA8js","_id":"060ba63a-e954-4a26-8b89-e3644d4182c4","_updatedAt":"2023-04-04T16:56:27Z"},{"_type":"author","_createdAt":"2023-04-04T16:56:47Z","lastName":"Roy","displayName":"Asim Roy, MD","_rev":"05EBP80VNrfeXCUddsbKne","_id":"a07fe816-4a1c-485e-ac77-27408d8adb76","_updatedAt":"2023-04-04T16:56:47Z","url":{"current":"asim-roy-md","_type":"slug"},"firstName":"Asim"}],"_updatedAt":"2023-04-21T14:55:27Z","summary":"Sleep experts present a case of an 18-year-old female preparing for college with EDS and cataplexy, and share their approach to treatment.","url":{"_type":"slug","current":"case-1-18-year-old-female-with-type-1-narcolepsy"},"_rev":"oqkP756WTbwkIHk9Ug6Qqa","updatedOn":null,"body":[{"_type":"video","videoID":"6323598514112","disableAutoPlayVideo":false,"source":"brightcove","_key":"6160eb860bf9"},{"_type":"block","style":"normal","_key":"ed260a8098f2","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: ","_key":"a1c49c503b230"},{"_type":"span","marks":[],"text":"I’m going to throw a couple of cases at you real quick, and I’m not going to go into great detail, but the one that comes to mind is an 18-year-old female. She’s getting ready to go to college. She’s worried about whether she can go to college because she has profound daytime sleepiness. Her Epworth Sleepiness Scale score is around 18. She’s fallen asleep in class in high school. She’s very smart, but her performance has been worse because she can’t stay awake for the exams and classes. Then she has these spells where her brother likes to surprise her, her brother sneaks up and surprises her, and she collapses, and completely loses muscle tone. It lasts only a minute or so, and she doesn’t fall, she just melts into the floor. She can still hear him laughing, she hasn’t fainted, she has just lost muscle tone. The family obviously was alarmed. She developed all these personality changes, was irritable and depressed, and all of this, worrying about whether she can go to college or not. She was seen by a cardiologist for arrhythmia, and eventually seen by a neurologist for a seizure disorder, and by a psychiatrist as well. But she described these vivid dreams, colorful dreams, and she had episodes of panic attacks at night when she would wake up and would panic and feel as if she couldn’t breathe. She was treated for attention deficit disorder as well with methylphenidate, but she was normal otherwise. Have you seen a case like this before?","_key":"a1c49c503b231"}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"ebe4af1d43a00"}],"_type":"block","style":"normal","_key":"36cb1b1a2e50","markDefs":[]},{"_type":"block","style":"normal","_key":"a6ae80df2886","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"9436c8dda0cf0"},{"_type":"span","marks":[],"text":": Quite a few.","_key":"9436c8dda0cf1"}]},{"_key":"ad134b37a1eb","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"01e094c2c0f50"}],"_type":"block","style":"normal"},{"style":"normal","_key":"3a15d02d9cee","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: ","_key":"9b4ee403a24a0"},{"_type":"span","marks":[],"text":"Can you explain what was going on?","_key":"9b4ee403a24a1"}],"_type":"block"},{"markDefs":[],"children":[{"text":"","_key":"1db20cb93c8a0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"b6edfb36afaf"},{"style":"normal","_key":"12302ec9d8bf","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"826ef48afcc30"},{"_type":"span","marks":[],"text":": This sounds pretty classic for type 1 narcolepsy. Obviously, the excessive daytime sleepiness [EDS] is not unique to only narcolepsy. But you combine that with this startle response with atonia, and still being aware of her environment when she collapses or melts into the ground, is kind of that classic cataplexy description, where it’s ruled out syncope, ruled out most likely generalized seizure at least. It could still be partial seizures, but again, the probability of having that long of a duration and still being aware of your environment and bilateral, it’s most likely cataplexy. All the REM vivid phenomena, vivid dreaming, this is classic type 1 narcolepsy.","_key":"826ef48afcc31"}],"_type":"block"},{"_type":"block","style":"normal","_key":"b4a09ef31d43","markDefs":[],"children":[{"_key":"4f518bda9a930","_type":"span","marks":[],"text":""}]},{"_key":"4b4d3fbe2d99","markDefs":[],"children":[{"_key":"867399c427380","_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM:"},{"_key":"867399c427381","_type":"span","marks":[],"text":" The thing is that this poor girl didn’t realize she was sleepy. She knew she was falling asleep in class, but quantitatively, she didn’t know. I think it’s good to point out that the peak incidence of narcolepsy is right around age 15 or 16. Part of that as you pointed out is related to the autoimmune system. The autoimmune system is revved up at that age. If you get the flu or mononucleosis, and you kill the bug, and if you have HLA DQB1*0602 positivity, your HLA phenotype is right, and all the stars align, you might knock out those orexin neurons and develop type 1 narcolepsy."}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"d095205298a20"}],"_type":"block","style":"normal","_key":"a3d21537dcb3"},{"_type":"block","style":"normal","_key":"2587f9245221","markDefs":[],"children":[{"_key":"7757b709b0800","_type":"span","marks":[],"text":"There is a drug available to treat cataplexy in a teenager. Now she’s 18, so she’s technically an adult, but if she were 15, what do you think would be the drug of choice?"}]},{"style":"normal","_key":"3b8e447e073b","markDefs":[],"children":[{"_key":"77d63b2303f10","_type":"span","marks":[],"text":""}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"6f52e808233b0"},{"_type":"span","marks":[],"text":": We would have to go with oxybate. It’s the only FDA-approved option for age 7 and above, for pediatric cases of narcolepsy. If she was under that age bracket, oxybate, whether it’s sodium oxybate, low-sodium oxybate, and potentially there’s this new, emerging once-a-night oxybate that’s going to be coming out soon. This would be the discussion I would have with her and her family.","_key":"6f52e808233b1"}],"_type":"block","style":"normal","_key":"223e44b22ddd"},{"_key":"a6c6f34e87c2","markDefs":[],"children":[{"text":"","_key":"3bd3f651eefc0","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"67d600b698590","_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: "},{"_type":"span","marks":[],"text":"Sure. We always have to clinically correlate and see what the environment is. But I think it’s important for them to understand quantitatively how sleepy they are, but also understand what’s happening. 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Is there an unmet need, and what are we looking at?","_key":"3db15b61e6a61","_type":"span"}],"_type":"block","style":"normal","_key":"b64afc81971a","markDefs":[]},{"children":[{"marks":[],"text":"","_key":"58b62ab6d39c0","_type":"span"}],"_type":"block","style":"normal","_key":"b92a3db43fc9","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"ad1aabb52a580"},{"_type":"span","marks":[],"text":": When we go back to what’s the underlying physiology in type 1 narcolepsy, it’s orexin deficiency. We clearly know that today. With everything we’ve talked about up to this point, none of them target orexin, they’re all targeting these downstream neurotransmitters. For me, that’s a huge potential future therapeutic space, if we can get to orexin and enhance the orexin system, the potential benefit of these downstream neurotransmitters might inherently occur without relying on these other drugs. That smoothness or that stability of wakefulness might occur when we have orexin agonists. There are a lot of unknowns still, but we suspect that by targeting the underlying…it’s like giving a type 1 diabetic metformin, or a GLP-1 [glucagon-like peptide-1 agonist], or whatever, you’re not giving them insulin, which is what they’re not making. They still need insulin. That’s how I look at type 1 narcolepsy. If we can’t give them orexin, we’re “Band-Aiding” the situation at this point.","_key":"ad1aabb52a581"}],"_type":"block","style":"normal","_key":"3b30a6d255ad"},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"7f67b1ff32280","_type":"span"}],"_type":"block","style":"normal","_key":"23731b00466e"},{"style":"normal","_key":"5130e4233214","markDefs":[],"children":[{"_key":"2406cd38df7a0","_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM:"},{"_type":"span","marks":[],"text":" I think the Band-Aid is helping a lot, but there are unmet needs as you say.","_key":"2406cd38df7a1"}],"_type":"block"},{"style":"normal","_key":"997028a9252e","markDefs":[],"children":[{"_key":"a55de17cd4ca0","_type":"span","marks":[],"text":""}],"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"fea9855f18d10"},{"_type":"span","marks":[],"text":": There’s still a huge unmet need, but it’s better than nothing. These patients, usually when we see them, if nothing’s worked for them or they’ve had a lot of adverse effects and they’re really stuck, they have no solution, a lot of them are left pretty disabled. They can’t work or they can’t function as well as they would like.","_key":"fea9855f18d11"}],"_type":"block","style":"normal","_key":"e522e7d058ff","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"","_key":"a152586d53130"}],"_type":"block","style":"normal","_key":"22737332f2fb","markDefs":[]},{"_type":"block","style":"normal","_key":"aca709327870","markDefs":[],"children":[{"text":"Richard K. Bogan, MD, FCCP, FAASM:","_key":"0d40980cd0740","_type":"span","marks":["strong"]},{"_key":"0d40980cd0741","_type":"span","marks":[],"text":" I think an important message from an orexin standpoint is, orexin is so important because it’s not only promoting the awake circuits, but it’s doing other things. It makes us breathe more. We breathe more when we’re awake, so we breathe more. It affects the hypothalamic-pituitary axis. Orexin does a lot of stuff, so it’s going to be really interesting to see what these orexin agonists do. How much effect do they have on the REM dissociative symptoms at night, as well as the cataplexy? That will be pretty fascinating. We’re early into the research, and of course, we encourage everyone to watch for this. And people are picking off some of the other receptors, norepinephrine reuptake inhibitors, and other ones."}]},{"markDefs":[],"children":[{"text":"","_key":"7a945f5c6ca00","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"f08ceefd72a1"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD","_key":"7707093566a00"},{"_type":"span","marks":[],"text":": Correct. There are more histamine agonists coming.","_key":"7707093566a01"}],"_type":"block","style":"normal","_key":"1710522dfa48"},{"_type":"block","style":"normal","_key":"d430d4a7a322","markDefs":[],"children":[{"text":"","_key":"6354afb7d2230","_type":"span","marks":[]}]},{"_type":"block","style":"normal","_key":"b16acce0b5ba","markDefs":[],"children":[{"text":"Richard K. 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Bogan, MD, FCCP, FAASM","_createdAt":"2020-09-24T13:36:06Z","_type":"author","url":{"_type":"slug","current":"richard-bogan-md"},"firstName":"Richard","_rev":"VK3VX4M8foqKA88p8UA8js","_id":"060ba63a-e954-4a26-8b89-e3644d4182c4","_updatedAt":"2023-04-04T16:56:27Z","lastName":"Bogan"},{"displayName":"Asim Roy, MD","_rev":"05EBP80VNrfeXCUddsbKne","_id":"a07fe816-4a1c-485e-ac77-27408d8adb76","_updatedAt":"2023-04-04T16:56:47Z","url":{"current":"asim-roy-md","_type":"slug"},"firstName":"Asim","lastName":"Roy","_createdAt":"2023-04-04T16:56:47Z","_type":"author"}],"summary":"Richard K. Bogan, MD, FCCP, FAASM, and Asim Roy, MD, comment on the evolving treatment landscape for narcolepsy and patient selection of FDA-approved agents: solriamfetol, pitolisant, and lower-sodium oxybate.","internalTag":["newer agents","narcolepsy"],"ExcludeFromPubMedXML":false,"published":"2023-04-11T19:13:00.000Z","is_visible":true,"seoTag":["narcolepsy","solriamfetol","pitolisant","lower-sodium oxybate","Epworth Sleepiness Scale","oral contraceptives","stimulant","type 1","type 2"],"_type":"article","documentGroup":{"_ref":"6d118f7b-44de-4ff5-bc51-283e88e9d7c4","_type":"reference"},"documentGroupMapping":[{"_key":"5af9be18946c","_ref":"6d118f7b-44de-4ff5-bc51-283e88e9d7c4","_type":"reference"}],"body":[{"_key":"5e47ff363a96","_type":"video","videoID":"6323887713112","disableAutoPlayVideo":false,"source":"brightcove"},{"children":[{"marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: ","_key":"dd32358b846c0","_type":"span"},{"text":"I know you’re going to talk about solriamfetol as an option. It was developed primarily to meet an unmet need. These individuals are still sleepy, and not all medications work satisfactorily. Tell me about solriamfetol.","_key":"dd32358b846c1","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"785e9648a047","markDefs":[]},{"style":"normal","_key":"b3fcc6c33316","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7dee938f6d030"}],"_type":"block"},{"_key":"ec6b43efc1a0","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD:","_key":"cfbb83c55b530"},{"text":" That came into the mix around the same time as pitolisant. It’s a dopamine norepinephrine reuptake inhibitor. If we think about other drugs and mechanisms of action, bupropion is probably the closest in terms of mechanism of action that solriamfetol is similar to. Probably the only tweak or difference is the nicotinic receptor that bupropion has an effect on but solriamfetol does not. Otherwise, it has shown to be a potent alerting effect. It’s not for everyone, but in patients who respond well, it has a long duration of action. A lot of times with stimulants, especially short-acting stimulants, you have to dose these individuals 2, 3, sometimes even 4 times a day to give them 2- or 3-hour chunks of alertness. If we can provide therapy once in the morning that can sustain them for 9, 10, or 11 hours, that has some huge positive compliance benefits, Patients also prefer something that’s smoother throughout the day. This is where pitolisant also has a long duration of action. Armodafinil, the sister version of modafinil, has a little longer duration of action. These are the therapies that can be given in the morning and that can hopefully sustain an individual throughout most of the day.","_key":"cfbb83c55b531","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"children":[{"_key":"5f7768a9cbd30","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"2ccc2214fcd9","markDefs":[]},{"markDefs":[],"children":[{"text":"When we look at the oxybate world, this is the only nighttime therapy that targets GABAB receptors in the brain. The orexin system maintains that wakefulness, but as it decreases in the evening or at night, the GABA system takes over to put the brain to sleep. Oxybate targets GABAB. When we think of benzodiazepines, traditionally they work on GABAA and GABAB but potentially a little more on GABAA. There are only a few that are selective to that GABAB receptor, which we believe helps stabilize sleep. It works in these individuals with narcolepsy and idiopathic hypersomnia, which was a recent FDA approval, using a low-sodium oxybate version.","_key":"4492e3fbf6e40","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"d3925cc1fcf2"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"46effb7c26d40"}],"_type":"block","style":"normal","_key":"a77cdbdb2513"},{"style":"normal","_key":"bea78710517e","markDefs":[],"children":[{"_key":"ba31fbf21ad60","_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: "},{"_type":"span","marks":[],"text":"One other comment about solriamfetol, and then I want to ask you, how do you decide which 1 you’re going to use in your patients? It’s worth pointing out that in the clinical trials, when we looked at the Epworth Sleepiness Scale score, and we looked at the MWT [maintenance of wakefulness test], which is the MSLT [multiple sleep latency test] backward. Instead of telling them to fall asleep, we tell them to stay awake, and we measure. The effect size with solriamfetol was impressive in terms of the Epworth score, as well as the maintenance of wakefulness test, and it’s renally excreted. Some drugs are metabolized through the liver, and some will interfere with birth control pills. I’m sure you’re going to talk about that. Solriamfetol is 1 of the main drugs that doesn’t have an effect on oral contraceptives. It doesn’t enhance the safe enzyme system that has an effect on neural contraceptives. That’s something we take into account when we decide what therapy we’re going to use. How do you decide what to use?","_key":"ba31fbf21ad61"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"","_key":"97545793f6010"}],"_type":"block","style":"normal","_key":"1e5ab46ad79c","markDefs":[]},{"style":"normal","_key":"8b430ff9a6c7","markDefs":[],"children":[{"_key":"e609b54942090","_type":"span","marks":["strong"],"text":"Asim Roy, MD:"},{"_type":"span","marks":[],"text":" The payer world, the insurance world, is going to dictate some of our pathways despite what we might feel is a better choice or something we’d like to start with. Traditionally, modafinil and armodafinil is where we’ll end up starting with the generic. They’re effective, but they’re liver metabolized. They have some drug-drug interaction with the oral contraceptive. We’ll have to counsel our patients about that, but it’s invariably something that we’ll need to consider as our first-line agent.","_key":"e609b54942091"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"50edd4f93ca20"}],"_type":"block","style":"normal","_key":"59356959d59e"},{"_type":"block","style":"normal","_key":"7926b7e7cfd2","markDefs":[],"children":[{"text":"Once we’re past that point, meaning they’ve tried it and it might be helping them a little, or they’re not seeing a big response, our goal is to introduce a second agent. I decide that based on symptomatology. If they have cataplexy, I’ll go after the anticataplectic therapies more aggressively and a little sooner. That’s going to be a decision between pitolisant or an oxybate. That’s an open discussion with the patient about the mechanism of how they work. What’s the value of using 1 over the other? What are the advantages of doing something in the daytime? What’s the advantage of doing something at night? Maybe we may need to consider both down the road. That’s the discussion. If they have type 1 narcolepsy after a modafinil failure or armodafinil not responding as well, I’ll try to go after anticataplectic therapy.","_key":"26ab3bd1b7c10","_type":"span","marks":[]}]},{"_key":"e338ccec7b86","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"cf03b6f086c40"}],"_type":"block","style":"normal"},{"style":"normal","_key":"4d2f80ea9c99","markDefs":[],"children":[{"_type":"span","marks":[],"text":"However, for most other patients—type 2 narcolepsy and IH [idiopathic hypersomnia]—we’re going to be considering a stimulant at this point, or I’ll consider solriamfetol. The discussion is that for 50% to 60% of our patients, at least in our clinic, modafinil or armodafinil didn’t work. Solriamfetol still has a great chance of working in that patient pool. It’s an option that’s worth considering if we can stave off a stimulant. Our philosophy is starting to move away from stimulants as much as possible, but it’s hard to avoid completely. If we can get to a point where they’re using only as needed—driving, afternoon meetings, situational—then it’s an ideal scenario in my book, but some patients can’t avoid relying on stimulants. It’s going to be a wake-promoting agent, which is modafinil, armodafinil, or solriamfetol, and then most likely a stimulant. In that discussion afterward, pitolisant and oxybate come up as a close third. It’s a 1-on-1 discussion with the patient on which of these seems best. Based on their lifestyle and situation at home, 1 may be more advantageous than the other.","_key":"ccd8c231f6670"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"5351d8f52bfb0"}],"_type":"block","style":"normal","_key":"c21e7b02ccf2"},{"_type":"block","style":"normal","_key":"24ed0beddcd7","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: ","_key":"55bcfe0b6d180"},{"_type":"span","marks":[],"text":"There are a lot of chefs who have different recipes, but your outline is entirely appropriate. In my clinic, with stimulants, the problem is tolerance and adverse effects. We’re all intrinsically sleepy in the afternoon; it’s siesta time. These patients are already sleepy, and then you add that on top of it. It’s not unusual for us to use a little rescue methylphenidate in the afternoon to get them over the hump. Because if they can get it over the hump and get into the evening hours, then sometimes they’re doing better. But I agree with what you’re saying.","_key":"55bcfe0b6d181"}]},{"_key":"91ee35d38857","markDefs":[],"children":[{"_type":"span","marks":["strong","em"],"text":"Transcript Edited for Clarity","_key":"1eae2543a666"}],"_type":"block","style":"normal"}],"url":{"current":"newer-agents-for-the-management-of-narcolepsy","_type":"slug"}},{"showSocialShare":true,"documentGroupMapping":[{"_ref":"6d118f7b-44de-4ff5-bc51-283e88e9d7c4","_type":"reference","_key":"e092997b29e7"}],"taxonomyMapping":[{"_updatedAt":"2020-11-24T17:56:01Z","identifier":"case-based-psych-perspectives","_createdAt":"2020-11-24T17:56:01Z","_rev":"73J0FFI1KHIHew3z5vnvMP","_type":"taxonomy","name":"Case-Based Psych Perspectives","_id":"0fa9d547-ec74-4619-a777-a09ead3235ff"},{"name":"Sleep Disorders","_updatedAt":"2023-03-31T19:33:18Z","identifier":"topics/sleep-disorders","parent":{"_ref":"pst_taxonomy_53202_clinical","_type":"reference"},"perKeywordMapping":["Psychiatry","Neurology","Pulmonology"],"_type":"taxonomy","_id":"pst_taxonomy_694_sleepdisorders","cmeType":"per","_createdAt":"2020-03-26T06:11:21Z","_rev":"37333Uv1mHMuPikcnyBeKU"},{"identifier":"topics/sleep-wake-transition","parent":{"_ref":"pst_taxonomy_694_sleepdisorders","_type":"reference"},"_createdAt":"2020-03-26T06:11:21Z","_rev":"BmvClBuXMtNlljYu6nhdr9","_type":"taxonomy","name":"Sleep Wake Transition","_id":"pst_taxonomy_380_sleepwaketransition","_updatedAt":"2020-06-10T19:45:36Z"}],"_createdAt":"2023-04-12T13:10:15Z","factCheckAuthorMapping":null,"source":null,"internalTag":["therapeutic options","narcolepsy"],"is_visible":true,"url":{"_type":"slug","current":"therapeutic-options-for-the-management-of-narcolepsy"},"seoTag":["narcolepsy","treatment","stimulants","modafinil","first-line therapy","sodium oxybate","pitolisant","antihistamine"],"authorMapping":[{"lastName":"Bogan","_rev":"VK3VX4M8foqKA88p8UA8js","_id":"060ba63a-e954-4a26-8b89-e3644d4182c4","_updatedAt":"2023-04-04T16:56:27Z","firstName":"Richard","displayName":"Richard K. 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Bogan, MD, FCCP, FAASM: "},{"_type":"span","marks":[],"text":"When we talk about orexin and orexin downstream, hitting dopamine, norepinephrine, and all that, how does that translate into therapeutic options? Would you review top-line categories and mechanisms of action? We’ll talk later about why we choose which ones.","_key":"3fa56c0373551"}],"_type":"block","style":"normal","_key":"cb15bb154857"},{"style":"normal","_key":"e7201dd8654a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"448d25d0af360"}],"_type":"block"},{"_type":"block","style":"normal","_key":"419b2e2f1756","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD:","_key":"63fd455dfad70"},{"_type":"span","marks":[],"text":" What’s amazing, and what I’m grateful for, is that in the last few years, a plethora of options have started to emerge in our toolbox. Even 5 to 10 years ago, we were pretty limited in what we could offer. From the 1950s, ’60s, and ’70s, stimulants were the mainstay of therapy. Dopaminergic agents would increase the amount of adrenergic or noradrenergic neurotransmitters in the brain. They’re effective, but they also come with adverse effects. We have to weigh that in terms of tolerability, the impact on anxiety, cardiovascular impact on heart rate, blood pressure, jitteriness, and things like that—if you overstimulate someone, essentially.","_key":"63fd455dfad71"}]},{"_key":"86c58ed7f433","markDefs":[],"children":[{"text":"","_key":"a353c19ff5d90","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"4b369f9080e20","_type":"span","marks":["strong"],"text":"Richard K. Bogan, MD, FCCP, FAASM: "},{"_type":"span","marks":[],"text":"Tolerance is another 1.","_key":"4b369f9080e21"}],"_type":"block","style":"normal","_key":"a1edc8d1d779"},{"_key":"441377ab15ef","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"5b4c604f895f0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"487fbceb4929","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Asim Roy, MD:","_key":"0cd3c5cf97fd0"},{"text":" Yes, tolerance is another big issue we’d have to deal with. The stimulant world was where we were originally. In the 1980s and early ’90s, modafinil came out. At that time it was the newest therapy in that arena, in terms of a dopamine reuptake inhibitor. Around the same time was the development of atomoxetine, which is a norepinephrine reuptake inhibitor. We had newer tools that don’t necessarily increase the amount of dopamine or norepinephrine. They just block the reuptake to maintain a sustained level. Even today, modafinil and its sister drug armodafinil are considered first-line agents. They’re generic, they’re inexpensive, and they have a pretty good therapeutic profile with a relatively low adverse effect profile. Headache is the most common thing we hear. It tends to get better as time goes on for most patients. Sometimes nausea. Anything else is possible, but headache tends to be the 1 we hear most commonly.","_key":"0cd3c5cf97fd1","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"6f16e87d0cd50"}],"_type":"block","style":"normal","_key":"24e8d742d9f9"},{"children":[{"text":"The dopamine reuptake inhibition from adapting to armodafinil was the mainstay of therapy. In the early 2000s, sodium oxybate came onto the market. That’s when it was FDA approved for cataplexy and daytime sleepiness and narcolepsy. For a long time that was essentially our arsenal. In the last few years, we’ve opened our neurotransmitter targeting to the histamine space. To this point, we’ve been able to target dopamine, norepinephrine, and serotonin, but we don’t typically see as robust of an alerting effect with serotonergic agents. Sometimes we see alerting effects with venlafaxine, but we don’t rely on most serotonergic agents for alerting. They have potential benefit from a cataplexy perspective but not from an alerting mechanism.","_key":"3cdf80030ab60","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"11448fbfc4de","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"bb2b5f313f7b0"}],"_type":"block","style":"normal","_key":"9e748e50b1b6"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"About 4 years ago, pitolisant came onto the market. It was available in Europe originally, and then FDA approved it in the United States. This is a histamine agonist. It has a weird mechanism of action. It’s interesting in terms of how it works. Most people know histamine from the antihistamine world—most commonly H1 receptor antagonist and H2 receptor antagonist. We know how they work: diphenhydramine or some of the newer antihistamines typically target that H1 receptor; H2 is predominantly in the gut. Pitolisant works is in the brain, on H3. H3 is commonly located in the presynaptic cleft, in the histamine neurons, which is in the TMN, the tuberomammillary nucleus. It’s adjacent to where the orexin neurons are, and it’s the only place in the brain where histamine is produced. These H3 receptors are normally self-regulating. If your brain is making enough histamine, histamine will then bind to H3 and tell the neurons to stop making more; we have enough. Pitolisant blocks that H3 receptor from histamine binding to it. The neuron will continue to make histamine, so there’s no self-regulation anymore. It also has an agonist effect, so it will tell the neuron to produce even more histamine than it normally would. With this downstream effect, we’re getting increased histamine in the synaptic cleft, which will bind to H1 in the brain. If you think of antihistamines, the ones that cross the blood-brain barrier we typically know will make you very sleepy. One of the most common over-the-counter sleep aids targets antihistamines. It’s important to think about what crosses into the brain, what stays systemic. From a pitolisant standpoint, if you can avoid antihistamines that don’t cross into the brain, it’s very effective. 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