Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How are you thinking about incorporating mirtazapine into your treatment approach for patients with methamphetamine use disorder?
In my experience as an addiction psychiatrist in Maryland, I always found mirtazapine to be a low-hanging fruit in my "dual diagnosis" patients, re: reasonably quickly helping with insomnia and poor appetite that comes with drug use or especially opioid withdrawal. Also comes with the potential plus...
Do you have any concerns about administering a Vivitrol injection when a patient has severe coagulopathy and/or thrombocytopenia related to cirrhosis?
Although the risk of transaminitis is overall low, I do try to be more conservative when patients have evidence of severe cirrhosis or decompensated cirrhosis. If naltrexone is the best choice, I will typically start with oral naltrexone and check labs to ensure that they are stable. And if the pati...
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...
What non-pharmacologic interventions or resources do you recommend for parents of patients with severe anxiety?
It depends on the type of anxiety, but a few things that I have found helpful over the years... Education about the physiology of anxiety, amygdala info, and the body’s response/cycle to anxiety is key. Help the patient understand that the goal cannot be to “get rid of” all anxiety; trying to contr...
What findings help you differentiate between catatonia and NMS?
This is a cogent and very interesting problem that is not uncommon, especially in emergency rooms. In the spirit of full disclosure, your author must admit to a theoretical approach to this topic that views catatonia and Neuroleptic Malignant Syndrome (NMS) as both being forms of catatonia, with dif...
What are your preferred methods for QTc calculation for normal, tachycardic and bradycardic heart rates?
This depends on the need for precision. If for clinical purposes, the Fredericia correction formula will suffice and is less sensitive to heart rate distortion than Bazett's. If the goal is to precisely define the QT interval in a clinical trial, such as a thorough QT study of a new chemical entity,...
How have you incorporated Eye Movement Desensitization and Reprocessing (EMDR) into your outpatient psychiatric practice?
Training is formal and takes one week, and the training I had was truly excellent and experiential. The EMDRIA website has a list of trainers and trainings. I have found EMDR to be a powerful modality that rapidly clears the negative emotions related to past traumatic or unpleasant events. I use it ...
Have you used cannabinoid-based products for insomnia?
No, but patients report it helps. I don't encourage it due to a lack of research supporting long-term positive effects.
Do you find that hydroxyzine worsens cognitive symptoms in patients who are already susceptible to cognitive impairment?
Hydroxyzine should not have a direct negative effect on cognition. For decades after its inception, it was lopped in with Benadryl in terms of its receptor binding affinity profile and is listed in several anticholinergic burden scales as being anticholinergic. Similar to the child’s game ‘telephone...
Have you used lithium for agitation in dementia?
Non-pharmacologic approaches are first indicated. If they fail, then a psychotropic treatment algorithm is indicated, which generally starts with a serotonin reuptake inhibitor. Lithium would not be considered standard or first-line treatment for agitation in Alzheimer's disease, and in most other m...