Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients on the risks and benefits of antidepressant use during pregnancy?
I always frame the decision as being between the risks and benefits of the medication vs. the underlying condition. We are always aiming for the "minimum effective dose" but "effective" is just as important as "minimum." Medications are, of course, not the only way to treat psychiatric illness and a...
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...
Do you find consumer grade wrist actigraphy useful in measuring sleep quality and duration?
Consumer wearables are advancing quickly, and there is a lot of variation in their performance, particularly in those with sleep disorders. Unfortunately, there is a wide variation in the performance of devices, even ones using the same signals to calculate sleep/wake. Additionally, orthosomnia is a...
What pharmacological management do you consider in patients with Autism Spectrum Disorder whose primary behavior is aggression?
As with all of my child patients, my approach is never to medicate behavior but rather to medicate suffering. This means that I view “aggression” of all forms as a kind of communication that something is wrong inside and that other means of effective communicating or managing that discomfort or what...
When do you consider lithium for early intervention in those identified to be at risk for bipolar disorder?
Lithium is the preferred first-line agent for bipolar disorder. It offers patients the potential for as close to a cure (restituo ad integrum) as you can get in psychiatry. For this case, I would initiate a 150 mg dose, and potentially build to a low-moderate dose (300-450 qhs) and watch and wait ov...
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...
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.
What is your next step in management for patients who develop sexual side effects on an SSRI (anorgasmia, low libido, etc.) but are responding well to therapy?
Managing side effects from SSRI medications is a key component of treating patients in the outpatient setting who are suffering from depression and/or anxiety. This is doubly true given the fact that primary care is often the most accessible, and often most trusted, source for patients to make their...
What are the main confounding variables you ask about and monitor in patients with depression and anxiety?
It is critical to rule out bipolarity, which is often missed. The other major issue is to investigate the possibility of medical comorbidities, which may be causing or contributing to the mood disorder and anxiety. Check labs and other issues, including imaging. Review all past records you can find....
After a medication overdose, do you restart that same medication if the patient reports it had been effective?
This is a good question, because intuitively it doesn't make sense to resume it (also, you would look really bad if your patient OD'd on the same medication that you prescribed). Truth is, patients can OD on anything. Generally, in my experience, people OD on meds that make them sleepy because they ...