Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What has your experience been counseling on and prescribing Cobenfy?
I have good results from it - but just like with any medication in psychiatry, there isn't "one size fits all". There is data that shows a more rapid titration to the highest dose (125-30) works the best. It goes 2 days with 50-20, then 5 days with 100-20, then transitions to 125-30. You have to mak...
What is your approach to duration, dosing, and continuation of lithium monotherapy in patients with a single lifetime manic episode stabilized on lithium?
Sometimes lithium is the only thing that works for patients with bipolar disorder, and in those cases, we also need to look at the calcium level because long-term use can also cause hyperparathyroidism. This is why we should look at labs every 3-6 months to monitor. If lithium is the only thing that...
What are the main confounding variables you ask about and monitor in patients with depression and anxiety?
It is critical to rule out bipolarity, which is often missed. The other major issue is to investigate the possibility of medical comorbidities, which may be causing or contributing to the mood disorder and anxiety. Check labs and other issues, including imaging. Review all past records you can find....
How do you screen for unrecognized bipolar disorder before initiating antidepressant therapy in a patient presenting with a new depressive episode?
Because 60% of the index mood episodes with which children/adolescents (who will later be diagnosed with bipolar disorder) present are major depressive episodes, this is a very good question. It is important that clinicians do not precipitate a manic episode while treating a first depressive episode...
What do you recommend to patients when they are having an acute flare of fibromyalgia symptoms?
Great, this is a really important area and unmet need in the field of fibromyalgia management. Unlike other nociplastic disease states (e.g., migraine), there are no rigorously studied abortive therapies to rapidly treat a flare of centralized pain. Indeed, all the therapies we use for FM are intend...
How do you assess and adjust treatment in patients who develops hypothyroidism after being on lithium for several years?
It depends on whether the patient is symptomatic. If not, careful monitoring is all that is needed. If there are significant symptoms, treatment with levothyroxine would be needed. Continued use of lithium is appropriate if it has been effective over time.
How does comorbid epilepsy influence your decision on antipsychotic medications?
In general, epilepsy is not a contraindication to the use of antipsychotic medications if they are needed despite the known risk of lowering the seizure threshold. In general, the risk of seizures for most antipsychotics is low, though some antipsychotics, such as clozapine, olanzapine, and quetiapi...
How do you counsel patients with depression who ask about the role of the gut–brain axis (e.g., probiotics, diet, or microbiome-targeted interventions) in their symptoms?
I usually explain to patients that the gut–brain connection is real, and one of the most consistent findings is that diet matters. A Mediterranean-style, fiber-rich diet—high in vegetables, fruits, whole grains, legumes, and healthy fats—has good evidence showing meaningful improvement in mild to mo...
How do you approach initiating esketamine treatment in older adults with difficult-to-treat depression?
Definitely a tougher crowd to treat, in general, whichever treatment is chosen. All the aforementioned considerations come into play, but it is also important to note that esketamine works well in older patients and should be offered as a treatment if it is appropriate. Regarding preliminary conside...
How have you approached monitoring for severe side effects of ketamine treatments in the treatment of depression?
So... I'd say I'd never seen such severe side effects in my patients, and partially this is because ketamine infusions, done according to the expert guidelines (we use APA expert guidelines), are quite safe. We absolutely get a medical workup on every single patient, and we repeat the same workup on...