Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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, ...
What strategies have you found effective in improving acceptance of long-acting injectable antipsychotics in patients with serious mental illness who are ambivalent about treatment?
Good question. I think it's important to understand the patient's perspective, because everyone can have a unique fear regarding LAIs. It could be that they have a fear of needles, are concerned about a lack of autonomy, or are worried about the mechanism of action and potential adverse events. You ...
How would you treat psychotic symptoms in a patient with atypical psychotic-induced leukopenia with absolute neutrophil count (ANC) below 500 cells/µL (<0.5 x 10^9 L)?
I have not been faced with that situation except on Clozaril. I will use benzodiazepines initially to control anxiety and reduce the stress with psychotic symptoms. Later, when the white count starts to improve, I will initiate a different drug. Will go slow and check counts often enough not to miss...
What is your approach to using prazosin to treat day-time symptoms in PTSD?
I will only use prazosin during the day if the patient is using it for sleep disturbance/nightmares. If they are not using prazosin, then I prefer guanfacine during the day. If using prazosin, I start at 0.5 mg in the morning and then BID. I will titrate up based on reaction and side effects.
What is your approach to using newer atypical antipsychotics in the treatment of schizophrenia?
Latuda - great for mood stabilization and bipolar depression. A lot of people like it for borderline personality disorder, but it’s not FDA-approved for that. In my experience, not that great for psychosis or mania, but it also doesn’t really cause weight gain or QTc prolongation. Out of all the se...
How do you counsel patients who are hesitant to try behavioral therapies for insomnia instead of starting a sleep medication?
I try to be very understanding of the desire to have an easier solution to sleep difficulties, which are so common. It is challenging that our gold standard and best strategies to help people sleep better require a lot of effort on the patient's part. Starting with that validation can be very helpfu...
How have you incorporated prescription digital therapeutic treatments for chronic insomnia, such as SleepioRx or Somryst, into your practice?
I have not yet prescribed any of the digital therapeutic treatments, but there are key differences. The US Department of Veteran Affairs developed CBT-i Coach based on the therapy manual CBT for Insomnia in Veterans, and the app is free to use. CBT-i Coach is intended to augment face-to-face care wi...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
How do you counsel breastfeeding parents with postpartum depression when sleep deprivation appears to be worsening mood symptoms?
My position is that breastfeeding is a sometimes difficult practical issue, not a medical or moral imperative. I try to normalize the difficulties of breastfeeding, based on my own experience and that of my daughters and sisters, countering the exploitation of anxiety around this issue with problem-...