Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
In a frail older adult with depression unresponsive to two SSRI trials, what's your next step in management?
This is certainly a longer and nuanced conversation. Depends on the intensity of symptoms. Ensuring the diagnosis is accurate, reviewing the role of co-morbid cognitive disorders, organic issues masquerading as depression, and so on. Augmentation of an SSRI, e.g., mirtazapine, stimulating medication...
How do you weigh the risks of antipsychotic induced metabolic side effects when treating behavioral symptoms of dementia in a patient with diabetes?
This is an excellent question and is a difficult clinical metabolic risk concern in a poorly characterized population. Most of what we know about antipsychotic-induced metabolic syndrome, such as weight gain, dyslipidemia, insulin resistance, and hyperglycemia, comes from younger patients with schiz...
When do you use guanfacine instead of stimulant medication for adults with ADHD?
The short answer is that it just doesn't address the executive dysfunction experienced by most adults with ADHD who seek treatment. Adults who have that "hyperactive edge" about them (impulsive speech, interrupting, rapid topic changes, fidgeting) or who have significant irritability/aggression can ...
When do you order brain imaging in young adults presenting with first-episode psychosis in the absence of clear neurologic red flags?
You should always consider brain imaging, at least at CT, in the first episode of psychosis. While this will be negative almost 99% of the time, it's always good to rule out that population that may have something else going on in the brain that we can actually attribute the psychosis to. Also, chec...
How do you decide when dangerous or illegal behaviors in youth with conduct disorder require legal involvement?
This is a hard question to answer. If your JJ system provides support and treatment options, then it is useful for youth who can't be overseen by their caregivers to refer to JJ. However, many systems are more punitive and may not be helpful. In those situations, I would refer if the youth were enga...
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
What is your response when a high functioning adolescent with mild ASD features asks for an autism diagnosis?
The response to any child asking for any diagnosis is to explore the reason for the request. Why do they “want” it? What do they imagine would change were they to get the diagnosis? There are many possibilities. Is it to lessen their own shame about their struggles, as ASD is now a more “acceptable”...
What pharmacological management do you consider for self-injurious behavior in patients with autism spectrum disorder?
This is a great question but requires a nuanced answer. It all depends. In short, what I think the clinician needs to know is whether the patient with ASD and self-injury has a treatable condition that is driving self-injury. Perhaps the most critical is whether the patient has a medical problem tha...
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...