Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is the best approach to treatment for cenestopathies (sensation of electric current in patient's brain) accompanied by anxiety and inability to sleep?
Thank you for your question. Cenestopathies (referring to the feeling of being ill and this feeling not localized to one region of the body) may not be the correct term for this interesting phenomenon, commonly called "brain zaps". Brain zaps are a poorly understood symptom of antidepressant withdra...
Do you include a specific risk assessment in your outpatient clinic notes?
I typically include a risk assessment in my outpatient notes. I address the risk of violence and self-harm. I try to approach violence and suicide risk in a manner analogous to the primary care approach to cardiovascular risk: continuous risk reduction. In most outpatients, there is no imminent risk...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
How do you distinguish between antidepressants losing effectiveness vs. not being effective in the first place?
This is a common conundrum in antidepressant therapy. An antidepressant is prescribed, and the patient improves beginning 2-5 weeks later (perhaps after a dose increase), with remission following in the next few weeks. While continuing to take that antidepressant at the same dose (perhaps after seve...
How do you formulate and diagnose patients with chronic psychosis that developed after methamphetamine use but persists after cessation of use?
It may ultimately become schizophrenia that’s been unmasked by the stimulant use. I believe you need six months or maybe three months for a schizophreniform diagnosis, and then after that, it becomes schizophrenia if it meets all the other criteria. I have to check the DSM on the timeline.
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
I developed a structured, objective approach centered on PAWSS risk stratification and standardized mMINDS plus RASS monitoring rather than relying solely on symptom-driven tools like CIWA. At intake, patients with suspected alcohol use disorder undergo PAWSS assessment, baseline mMINDS scoring, RAS...
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 ...
How do you discuss lithium with patients who are hesitant due to concerns about side effects or monitoring requirements?
I inform patients that lithium is one of the oldest and most studied mood stabilizers. Many people do well on it for years with no or minimal side effects. Patients report that after years of suffering, it provides a sense of calm and helps with sleep. There is some evidence that it reduces suicide ...
How do you handle requests from patients to complete medical paperwork that falls outside your scope of practice when they cannot access their other clinicians?
These requests are relatively common and can come from the patient, a healthcare institution, or another institution, such as an insurance company or school. A subtype is the forensic document, which can come from an attorney, a local state, or a federal agency. At times, law enforcement agencies ma...
What non-medication interventions or resources do you provide parents of children with oppositional behaviors?
Behavioral therapies, including parent management training, are the most evidence-based treatments. For children under 7, a well-respected intervention is PCIT (Parent-Child Interaction Therapy). There are also the Triple-P Positive Parenting Program, Incredible Years, and Coping Power Program. The ...