Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients with mild to moderate depression interested in using St. John's Wort?
Although this is used in parts of Europe, there it is considered a pharmaceutical and has higher standards for dose and potency. Here, as it is a health food product, different batches may require different doses of the pill due to differences in potency. There is some data to suggest that the combi...
What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?
There was a time when the majority of patients did not want maintenance on an opioid agonist (methadone), and we did not have partial agonists (buprenorphine) available. This underlines how far we have come in the last 15 or so years. At that time, all we did was use the alpha2 noradrenergic agonist...
How do you approach the titration of Ambien (zolpidem) to treat catatonia?
I have no experience of using Ambien for catatonia, but have read an article from the NIH library, which shows a promising alternative when lorazepam does not work and ECT is not available readily. These are only case reports. Research is needed.
How do you discuss sexual and gender identity-related anxiety with teens when family dynamics are rigid or culturally conservative?
First and foremost is safety. Never put children or teens in danger by hostile family or neighbors. In other words, don’t out them or encourage them to out themselves if they don’t feel safe doing so. You never know how people around them might react. That means be careful with your documentation, t...
How do you counsel patients about the risks and benefits of mood stabilizers (e.g., lithium, lamotrigine) during pregnancy?
Great question! The risk of relapse for bipolar disorder mood episodes in women is at least as common during pregnancy as in the non-pregnant state, and discontinuation of medications increases the risk of relapse during pregnancy and postpartum. The majority of women who stop mood stabilizers for p...
What is your approach to recommending bright light therapy devices to patients with (seasonal) depressive disorders?
Bright light therapy has a strikingly positive evidence base for seasonal affective disorder, major depressive disorder, and even bipolar depression. I recommend shopping for a lamp with 10,000 lux, a large format, diffusion screen (possibly fewer headaches), and one that is on a stand so that it sh...
How do you manage ARFID in children encountered in your practice?
ARFID is a fairly new disorder, having been added to the DSM in 2013. Treatment somewhat depends on the type of ARFID with which the patient presents, although there are shared treatment elements regardless of type. Variants include Avoidant type, which usually revolves around sensory issues related...
What is your threshold for writing disability letters for patients with personality disorders?
I don't believe it's appropriate to have a threshold. Patients with personality disorders are often stigmatized and assumed to be manipulative or malingering. The criteria for writing a disability letter should be "Is the patient's disorder such that they are unable to work?" Assessing their recent ...
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...
What adjunctive therapies to you recommend for symptom control in acute opioid withdrawal beyond full/partial opioid agonists?
Here are some general recommendations below. I recommend asking the patient what symptoms are most bothersome or what they anticipate to be the most bothersome when prescribing adjuncts. I routinely recommend APAP/ibuprofen, and then usually prescribe something for anxiety and nausea. Tizanidine can...