Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach antipsychotic selection in a patient with a newly implanted pacemaker or ICD?
For patients with cardiac conduction abnormalities ziprasidone/chlorpromazine/thioridazine have the highest risk for QTc prolongation. Antipsychotics such as olanzapine and quetiapine have moderate risk with aripiprazole being least likely to cause prolongation of QTc. Implanted pacemakers do not ne...
What is your approach to giving sleep aids to patients who will not address their sleep hygiene habits or contributing comorbidities?
Always suggest CBT-I but also do brief CBT in the office. Sometimes it hits home, and they realize what they’re doing is self-detrimental, but often times they just want a pill to solve the problem. If you can get them motivated enough to go back to school or get a job, then that can help in rearran...
What does "verbal de-escalation" for agitation look like at your institution/practice?
As a geriatric psychiatrist, many of our patients have comorbid cognitive issues. Usually, nursing tries to de-escalate patients first; other staff might join as needed. We recommend not confronting symptoms of psychosis or agitation secondary to cognition. Trying to re-direct the patient away from ...
Which cognitive screening tools do you use when evaluating older adults with suspected dementia?
In keeping with Alexander Luria's (paraphrased) maxim that knowing what a patient gets wrong on cognitive screening is incomplete until you know why/how they erred, I'd say the tool used is less important than interpreting it. So, I don't worry too much about MMSE vs MoCA vs SLUMS (as long as the MM...
When is it useful to test for multiple amyloid-related biomarkers for patients undergoing work-up for cognitive impairment?
If a patient has a presentation consistent with MCI or early dementia due to AD (slow progressive decline, STM loss, no hallucinations, no neuro deficits), I will get an MRI and amyloid blood-based biomarkers. If the goal is just a diagnosis, I stop there. If they are interested in “mab” therapy, I ...
What medications best treat Intermittent Explosive Disorder?
Anecdotally (based on my experiences only), anything and nothing. It appears to be an intellectual/cognitive issue and most often a symptom of a wider pathology e.g., a history of trauma. Pharmacological treatments therefore seem only partially effective at best. With PTSD as the most common parent ...
How do you counsel patients who are interested in dietary approaches for managing major depressive disorder?
While balanced nutrition supports overall well-being, we must be cautious about narratives framing diet and exercise as outright replacements for medical psychiatric care. Overemphasizing diet risks setting patients with major mood disorders up for self-blame and perceived failure when lifestyle twe...
What factors lead you to counsel against tapering SSRI/SNRIs in a patient with stable major depressive disorder?
Number and severity of prior depressive episodes, prior suicide attempt, or serious thoughts. Stability of current life situation. I recommend not tapering if major life changes or stresses are likely to occur in the next six months. Lack of a supportive other who will strongly encourage the patien...
What is your pharmacological approach to treating depressive disorders in patients who develop serotonin toxicity?
I would try bupropion. Not Auvelity, as dextromethorphan has serotonergic activity. I would want to see if they were on any medication other than psychiatric that contributed to serotonin syndrome, like tramadol, and get rid of that or replace it as needed. I would probably want to transition to a n...
Do you believe that buspirone is ineffective in patients who are previously treated with benzodiazepines?
I've found buspirone helpful for patients who don't want to taper their benzo unless they have another medication on board. I wait until the buspirone is at a stable dose (typically at least 15 mg BID) before tapering the benzo. I specifically avoid cross-tapering/titration as I worry they will asso...