Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...
How do you approach patients who present repeatedly to the ED with suicidal ideation but no clear acute change in risk?
If a young patient presents repeatedly to the ED with SI, even if there is no change in acute risk, it is an indication that whatever is being put in place is not working well enough to support the patient, and/or a communication of the young patient's distress. This warrants a careful assessment of...
When do you consider using benzodiazepines to treat insomnia in patients with acute mania?
In acute mania in younger patients, benzodiazepines can be a very helpful adjunct to mood stabilizers when they are not able to control the hyperactivity and insomnia with mood stabilizers alone. In younger patients, I will go with longer-acting benzodiazepines, and in shorter-acting ones for older ...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
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 do you handle requests for disability or accommodations in clinical settings with limited administrative support or documentation time?
If you are working in private practice without ancillary support like case managers, I highly recommend having patients make appointments while you complete the forms for them. Clinically, if paperwork is being sprung on you out of nowhere, an evaluation is necessary anyways to determine if it's app...
How do you approach the role of professional home organizers in the treatment of patients with hoarding disorder?
This is a great question on a very rich topic! Here’s a brief summary of my approach. For treating hoarding disorder (HD), professional home organizers can serve as a valuable adjunct to standard care, but their role requires careful clinical framing, appropriate patient selection, and active coordi...
After remission from a first episode of psychosis how long do you continue antipsychotic treatment before attempting taper or discontinuation?
I don't think this is a one-size-fits-all question. This will depend on a number of factors. Probably most important is the client's attitude toward medication and their experience with it. Those who have done well with medication and have had no problems with side effects may be more comfortable co...
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
It is widely accepted that if liver enzymes are 3x above the normal limit, it is not advised to start naltrexone. Between 1-3x the upper limit, one has to do a pro and con analysis of whether the benefits of alcohol cessation would outweigh potential liver toxicity from naltrexone. Further, naltrexo...
What strategies have you found effective for obtaining insurance approval for xanomeline-tropsium (Cobenfy)?
Contacting the company and talk with their representatives and they can help facilitate the process, i.e. , resources to connect the patient with and/or samples until they can get it in a financially responsible manner