Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you decide who to rechallenge clozapine after it was discontinued for a neutropenic episode?
The clozapine rechallenge of the patient previously treated with clozapine but having it discontinued due to clozapine induced neutropenia or absolute neutropenia now has a sizable evidence-based literature suggesting that it can be done safely and successfully. Selecting patients with previous disc...
How have you approached monitoring for severe side effects of ketamine treatments in the treatment of depression?
So... I'd say I'd never seen such severe side effects in my patients, and partially this is because ketamine infusions, done according to the expert guidelines (we use APA expert guidelines), are quite safe. We absolutely get a medical workup on every single patient, and we repeat the same workup on...
How have you gone about implementing TMS in your practice or institution?
For me, the hardest issues with TMS are getting insurance to approve it and the time it takes from a patient’s perspective to see a benefit.When I first invested in the TMS machine, I calculated it could take up to 3 years to pay off the equipment cost. In actuality, I was able to recoup the initial...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
How do you counsel patients on cannabis use for PTSD?
In general, I recommend stopping cannabis. The large stratification study from the VA (sorry, only one cup of coffee and late night last night, so blanking on the authors or year) looking at patients who never used (19,000), chronically used before and during 3 months of treatment (2000), picked up ...
What has your experience been with using SSRIs to treat negative symptoms of schizophrenia?
Thirty years ago, I tried various SSRIs for negative symptoms, with no improvement according to the patient and caregivers.
How have you incorporated Eye Movement Desensitization and Reprocessing (EMDR) into your outpatient psychiatric practice?
Training is formal and takes one week, and the training I had was truly excellent and experiential. The EMDRIA website has a list of trainers and trainings. I have found EMDR to be a powerful modality that rapidly clears the negative emotions related to past traumatic or unpleasant events. I use it ...
How do you manage sleep disturbances in patients with Alzheimer’s disease without relying heavily on deliriogenic medications?
Sleep disturbances are common in older people and in those with Alzheimer’s disease (AD) in particular, and there are often multiple etiologies. Whether sleep disturbances increase the risk for AD, or are a result, metanalyses have suggested that the magnitude of sleep impairment correlates with the...
How long do you continue benzodiazepines in patients who have recovered from catatonia?
As others have already responded, it is case-dependent. In an otherwise healthy patient whose underlying medical or psychiatric condition causing catatonia had stabilized, there is likely a way to gradually taper off benzodiazepines without a risk of relapse.However there are other cases that are mo...