Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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 approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
Have you had success using lumateperone for behavioral symptoms in autism spectrum disorder?
While I have used this medicine successfully as an adjunct to an antidepressant or as a first-line treatment for bipolar disorder. I’ve never used it in autism spectrum behavioral management. In my experience, it is less sedating than Seroquel, so not as effective at helping people sleep.
What medications do you consider for adjunct treatment of conduct disorder?
This question is very complicated, not least because the assumption that comorbid disorders are being appropriately addressed also assumes that pharmacotherapy is underway. It is tricky to suggest a medicine treatment for conduct disorder without incorporating the medicine treatment for any comorbid...
What is your strategy for discontinuing benzodiazepines in patients with PTSD?
As always, remember that the person has developed habituation and dependency with subsequent definite withdrawal. In our clinic at the U of Miami, the protocol is the reduction, depending on the amount of dependency, of about 10 to 15% per month, sometimes requiring a compounding pharmacy. If you go...
How do you manage patients who send hostile or overly frequent messages through online patient portals in outpatient psychiatry?
This is a complicated yet important topic that should consider boundaries, diagnosis, threat assessment, and termination. Starting with boundaries, I think it is important for the clinician to establish the boundaries that they are comfortable with and share that information with the patient, all wh...
How do you screen for unrecognized bipolar disorder before initiating antidepressant therapy in a patient presenting with a new depressive episode?
I do not use a screening scale, and I do not think mental health professionals can justify their use of screening scales. There are no special questions on screening scales that mental health professionals are unaware of. So the question is why use a self-administered screening scale instead of aski...
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
Do you change your approach with medications for cannabis induced psychosis or mania?
I usually let it go for a day, and if there is improvement, then I don't initiate treatment but if on the second day and no improvement, then I usually start an antipsychotic as I would if I were treating a primary psychotic disorder aka based on metabolic profile and age.