Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients who are interested in dietary approaches for managing major depressive disorder?
While balanced nutrition supports overall well-being, we must be cautious about narratives framing diet and exercise as outright replacements for medical psychiatric care. Overemphasizing diet risks setting patients with major mood disorders up for self-blame and perceived failure when lifestyle twe...
For children under the age of 7 with ADHD who continue to have significant impairment with behavioral interventions, how do you decide between starting with a stimulant vs starting with an alpha agonist?
If the ADHD symptoms are still impairing despite being treated with behavioral interventions, pharmacotherapy is indicated. First-line pharmacotherapy for ADHD, even in elementary school-age or younger, is stimulants. I would treat them with stimulants unless there is a contraindication or a reason ...
What guidance do you give patients on fluvoxamine regarding caffeine intake?
Fluvoxamine is a potent CYP1A2 and 2C19 inhibitor. CYP1A2 is the major pathway for caffeine metabolism. In one small clinical trial, the half-life of caffeine increased from 5 hours to 31 hours during 50 mg fluvoxamine treatment (Jeppesen et al., PMID 8807660). Thus, I advise patients taking any dos...
When do you decide to stop prescribing controlled substances in patients who are also using cannabis?
The only controlled substance I prescribe is stimulants. If patients are using cannabis more than at bedtime or recreationally on the weekends, I will wean them off stimulants, as their effects will be limited by the significant cannabis use. I will do the same with alcohol.
What are your concerns regarding long term stimulant use in geriatric patients with ADHD?
I agree with @Dr. First Last; however, I had a patient in their mid-70s with small vessel disease (Parkinsonism) who had a gait disturbance, cognitive, and organizational problems. He was a lawyer who was trying to close his practice, and I gave him 10-20 mg of dextroamphetamine ER. It helped him co...
What is your preferred first-line agent to treat anxiety in patients with Parkinson's disease?
Any standard SSRI/SNRI can be tried. I like to try the SNRIs duloxetine or venlafaxine. If comorbid insomnia is a problem, mirtazapine may be a good choice. Think about talk therapy too. It is important to make sure episodic anxiety is not a non-motor symptom fluctuation related to levodopa or oth...
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
How do you approach a treatment relationship with a patient who is non-adherent to recommendations and also is not interested in transfer to another practitioner?
This situation superficially forces a provider to sit with frustration and perhaps resentment versus skirt the issue of abandonment. Some would (or would wish to) choose the latter and be ethically content to follow rules about providing referral information and a "buffer" period of continued care w...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...