Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What opportunities do you see for combining xanomeline-tropsium (Cobenfy) with other anti-psychotic agents?
The opportunities of combining Cobenfy with any of our other antipsychotic treatments, in my opinion, are unlimited. This is one of the most important aspects of its drug use that has NOT been systematically tested. One might think first of combining Cobenfy with a widely used drug, like risperidone...
What are your experiences with lithium target levels in the maintenance of bipolar 2 disorder?
I prefer maintenance lithium levels at the 0.7-0.8 range, because I wish to provide a more rigorous test of lithium's ability to prevent recurrence in each BPII patient.
How do you counsel patients on lithium about NSAID use?
I recommend not using NSAIDs altogether, since there are so many variables to consider if the patient is to remain safe. The patient needs to be highly aware and knowledgeable about their medications, medical problems, age, baseline labs, etc. There are not very many patients like that.
When do you consider writing an Emotional Support Animal (ESA) letter for patients with psychiatric illness?
After much soul searching, I decided that I cannot write these letters. The hard part for me is that I'm an animal lover and a pet owner, and I really do appreciate the happiness and comfort that a good animal companion can provide. But the letters are complicated, because for FHA benefits, you are ...
What pharmacologic and non-pharmacologic strategies have you found helpful in managing brain fog following COVID-19 infection?
In general, a systematic approach should be taken to evaluate COVID-19-related brain fog, which can then guide treatment. Additionally, brain fog following COVID infection can often be multifactorial, and the treatment accordingly often needs to be multi-pronged and comprehensive. The recommendation...
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...
When do you consider pharmacogenetic testing to assist in the selection of antipsychotic medications?
I don't usually consider it, as the evidence of clinical use isn't warranted unless the patient is on heroic dosing or has side effects to every medication. I usually will get plasma levels, and you can get plasma levels for pretty much any antipsychotic - it's a cheaper GeneSight. For example, if I...
How do you counsel patients/give data on long-term use of second generation antipsychotics and risk of involuntary movement disorders?
I never try to use SGA as an adjunct for MDD augmentation - if anything, it might be Caplyta (recently FDA approved and lower side effect profile). I have seen tardive dyskinesia from 1 year of Abilify with Zoloft from a PCP. So I am very hesitant to start an antipsychotic as an adjunct. But at the ...
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
How do you counsel patients who are interested in using kratom for chronic pain management?
I am not a pain management expert, but would recommend against use for chronic pain management. Risks outweigh in a significant order. It's not FDA-approved for any form of pain treatment. There is no dosage reference to use. The pain control one gets may be too low compared to the addictive risks, ...