Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to duration, dosing, and continuation of lithium monotherapy in patients with a single lifetime manic episode stabilized on lithium?
There are a number of variables involved here in making this decision. It only takes one manic episode in a lifetime to make the diagnosis of bipolar one. However, when deciding the duration of lithium, I would like to know what the rest of the patient’s mood trajectory has been. Are they pretty muc...
How do you decide whether to hold chronic medications with sedation potential in patients presenting with acute encephalopathy?
As soon as the patient comes, I recommend medication levels where possible to decide if essential medications with sedation potential should be stopped. Also, basic labs to get to the cause of the mental status change, including the scans and an EEG. In case all that is not possible, then depending ...
How do you approach the treatment of anxiety disorders in children with a significantly family history of bipolar disorder?
First, I always question the validity of a family history of bipolar disorder and clarify as best as possible bipolar 1 vs. 2. Nine times out of ten, it is "mood swings" that with further clarification were never formally diagnosed and were anger outbursts/irritability. If there is bona fide bipola...
How would you decide between escalation to clozapine vs xanomeline-tropsium (Cobenfy) for treatment-resistant schizophrenia?
Clozapine is the only agent FDA approved for treatment-resistant schizophrenia (TRS) as well as suicidality associated with schizophrenia or schizoaffective disorder. Clozapine has also robust anti-hostility and anti-aggressive effects as established in double-blind randomized clinical trials, inclu...
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...
Would you use bupropion for mood disorder or substance use in an adult patient with previous childhood seizures that resolved?
The short answer is maybe, though it would not be my first choice. Bupropion is known to lower the seizure threshold, thus the basis of the question. Selection of an antidepressant depends on multiple factors including response to prior medications, side-effect profile, cost, presence of comorbid sy...
Do you avoid triptans in patients on SSRIs due to the potential risk of serotonin syndrome?
I feel very comfortable using triptans with SSRIs/SNRIs. In 2010, the American Headache Society released a position statement on this very issue:Evans et al., PMID 20618823Their position is that the available evidence does NOT support the claim that triptans should not be used with SSRIs or SNRIs.A ...
Have you observed adverse mental health side effects in patients who start montelukast?
A female patient with anxiety but no history of depression or suicidal tendencies developed suicidal ideation with intrusive thoughts while taking montelukast. These were resolved within days of stopping the medication. I also treated a child brought in by his parents for extreme and sometimes viole...
What guidance do you give patients on fluvoxamine regarding caffeine intake?
Fluvoxamine is a potent CYP1A2 and 2C19 inhibitor. CYP1A2 is the major pathway for caffeine metabolism. In one small clinical trial, the half-life of caffeine increased from 5 hours to 31 hours during 50 mg fluvoxamine treatment (Jeppesen et al., PMID 8807660). Thus, I advise patients taking any dos...
What is your response when a high functioning adolescent with mild ASD features asks for an autism diagnosis?
The response to any child asking for any diagnosis is to explore the reason for the request. Why do they “want” it? What do they imagine would change were they to get the diagnosis? There are many possibilities. Is it to lessen their own shame about their struggles, as ASD is now a more “acceptable”...