Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?
There was a time when the majority of patients did not want maintenance on an opioid agonist (methadone), and we did not have partial agonists (buprenorphine) available. This underlines how far we have come in the last 15 or so years. At that time, all we did was use the alpha2 noradrenergic agonist...
How do you treat decreased libido from SSRIs?
Serotonin-1 agonism will revert it in about 60% of cases. You have a choice of adding buspirone at about 30 mg bid or going to vilazodone which has already an SR1 agonism. Some bupropion, not clearly understood at about 300 mg can also do it. Or if possible, use vilazodone, bupropion, or mirtazapine...
How do you taper antipsychotics being used for autism spectrum disorder if behaviors have been stable?
With sustained stabilization of behaviors - i.e., stable for 1 year - I start to taper very slowly, depending on how long they have been on a particular medication. This decision also depends on how severe the behaviors were prior to starting the antipsychotics, and whether or not they have any SEs....
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 ...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
When do you consider more aggressive options for insomnia in patients with autism spectrum disorder if first line agents have failed?
Addressing insomnia in individuals with autism spectrum disorder (ASD) is considerably more complex than it may initially appear. Because ASD encompasses a wide range of cognitive, behavioral, and functional profiles, it is unrealistic to expect a single approach to work across the entire spectrum. ...
How do you approach patients with fibromyalgia who are reluctant to consider a psychiatric component to their illness but present with clear mood or anxiety symptoms?
Since patients with fibromyalgia (FM) are often stigmatized and worried that clinicians think “it is all in my head,” it is important to discuss FM treatment and mental health referral from a biopsychosocial perspective. This might include introducing concepts such as the pain/depression dyad, centr...
How do you approach prescribing stimulants for ADHD in patients who are concurrently using cannabis?
Directly confronting cannabis use in ADHD assessments usually just makes patients defensive. Instead, I use a Motivational Interviewing approach, letting education do the heavy lifting early on. During the evaluation, I explain how THC products can heavily mimic and worsen core ADHD symptoms. Patien...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
In your experience, when do antidepressants begin to take effect for depression?
Postsynaptic down-regulation is known to occur at the four- to six-week mark. And I tend to delay dose changes until that point, if at all possible. Although this mechanism of action is now less solid with some of the meta-analysis data on the serotonin hypothesis, the time frame still holds for obs...