Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Which patients do you think would benefit most from xanomeline-tropsium (Cobenfy) monotherapy?
What we know best about this new drug, Cobenfy, a xanomeline-trospium combination, is that it does not directly affect the dopamine receptor, so it is novel and a new antipsychotic drug. And its antipsychotic efficacy has been demonstrated and accepted by the FDA. But still, we have a rather ‘pure’ ...
How do you identify and respond to possible elder abuse in patients with dementia?
Elder abuse, also known as elder mistreatment, includes psychological, physical, and sexual abuse; neglect, which includes caregiver neglect or self-neglect, and financial exploitation. Physical abuse includes the infliction of physical pain or injury to an older adult, which may result in bruises, ...
Which cardiac comorbidities prompt you to obtain cardiology evaluation before starting stimulant treatment in adults with newly diagnosed ADHD?
Cardiac conduction abnormalities are a concern, as the heart will be working harder with a stimulant on board, which can worsen conduction abnormalities. Also, anyone with cardiomyopathy has to be treated carefully, as the cardiac muscle has to work harder with stimulants on board. In both cases, pa...
Is there sufficient evidence yet to support the use of lithium supplementation or prescription in the management of neurodegenerative diseases?
No.I assume the question was written in response to a recent publication in Nature (Lithium deficiency and the onset of Alzheimer’s disease), highlighting recent research in mouse models where lithium deficiency in the brain led to accelerated amyloid pathology, which could be in part reversed by re...
How do you manage patients with bipolar I disorder who report emotional blunting or numbness while taking lithium?
Adjusting the once-daily bedtime dose to a lower level in the therapeutic range may help. I always tell patients that this is a recognized side effect of lithium. A discussion about the often unavoidable depressive episode following a manic episode may convince patients that avoiding a manic or hypo...
How do you address parental concern about children becoming addicted to stimulants for ADHD treatment?
In the current environment with an epidemic of fatalities from opiates, the question about addiction to stimulants is timely. I present the parents with the data, which shows that controlled dosing leads to a steady level of dopamine and does not produce a high. Further, studies find that treated ki...
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 medications do you consider for patients with premenstrual dysphoric disorder who do not respond to SSRIs?
In addition to emphasizing how helpful self-care can be (a little more sleep than usual, exercise, healthy nutrition, including limiting carbs, mindfulness), calcium carbonate 600 mg BID, judicious benzodiazepines, and gabapentin 100-300 mg hs can be helpful. Continuous OCPs can also be very useful....
How do you counsel patients about the risks and benefits of mood stabilizers (e.g., lithium, lamotrigine) during pregnancy?
Great question! The risk of relapse for bipolar disorder mood episodes in women is at least as common during pregnancy as in the non-pregnant state, and discontinuation of medications increases the risk of relapse during pregnancy and postpartum. The majority of women who stop mood stabilizers for p...
How do you approach pharmacologic treatment of sleep disturbances in perimenopausal or menopausal patients with vasomotor symptoms?
CBT-I is still the gold standard approach in this population, and sleep hygiene, relaxation, and sleep efficiency would likely be helpful whether you are also addressing vasomotor or other contributing factors. But it can be so helpful to directly treat vasomotor symptoms. I use gabapentin 100-400 m...