Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage patients who develop SIADH secondary to an SSRI but have had a strong positive response to that same medication?
Management of SSRI-induced SIADH depends on the severity of hyponatremia and the patient’s psychiatric response to treatment. In mild cases (serum sodium >130), I always continue SSRI with close monitoring and fluid restriction. Moderate to severe hyponatremia, I discontinue SSRI and actively correc...
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 ...
How do you incorporate psychological care into the surveillance and treatment of a pediatric patient found to have a cancer predisposition syndrome?
Psychological care is critical for patients with a lifetime genetically increased risk for cancer, with different needs at different stages of life.This was recently explored in an excellent article published in Pediatric Blood and Cancer "How We Approach the Integration of Psychological Services in...
At what point do you consider referring for neuromodulatory treatments (TMS, deep brain stimulation) for treatment refractory-OCD?
This is a fantastic question! Although I do not use a standardized "protocol" to determine when to refer for TMS or DBS, I typically think about this in terms of (a) medication trials, (b) comorbidities, and (c) OCD severity.Medication TrialsI would only consider TMS after trialing multiple serotone...
How do you manage expectations around response time and durability of benefit in patients starting TMS?
Re: response time, I tell patients it is typical to not notice a lot of change in the first few weeks. Sometimes the clinician will observe brightening of affect earlier, but the patient him/herself often does not notice a whole lot. I use the 'going to the gym' analogy... a few days will not yield ...
How do you counsel patients interested in neuromodulation (tDCS, rTMS) for ADHD?
i have not used rTMS for ADHD but have used for adolescent depression. It is advised to spend a full appointment to go over the evidence, the strength of evidence, possibilities of failure, etc. I generally let parents and patients come back to me to ask for the procedure. in my opinion, for any new...
How do you approach the management of behavioral disturbance/aggression in patients with a recent traumatic brain injury?
Subacute/Acute TBI agitation approach and managementIf in the inpatient setting, the first step is to optimize verbal deescalation, ensure adequate medical work-up has been completed to rule out contributing factors (such as pain, delirium, seizures), environmental and behavioral interventions first...
How would you decide between escalation to clozapine vs xanomeline-tropsium (Cobenfy) for treatment-resistant schizophrenia?
Clozapine is the only agent FDA approved for treatment-resistant schizophrenia (TRS) as well as suicidality associated with schizophrenia or schizoaffective disorder. Clozapine has also robust anti-hostility and anti-aggressive effects as established in double-blind randomized clinical trials, inclu...
How long do you continue benzodiazepines in patients who have recovered from catatonia?
This really is patient-dependent (as everything is in psychiatry). I have a patient currently who I have tried and tapered off over a year, but when I recently finally got him off completely, he started to become manic and catatonic again. I had him on an equivalent of 24 mg of Ativan in inpatient a...
When do you consider using Uzedy, the subcutaneous long-acting injectable version of risperidone?
It depends on how much risperidone they need. The maximum dose of Uzedy is only equivalent to 5 mg, so it’s not indicated for someone who needs more. The injection is different than Invega and has a smaller needle. It reaches steady state faster, but I have noticed a wearing off quicker in patients ...