Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
Is there a potential role for GLP-1 receptor agonists in the management of premenstrual dysphoric disorder?
This is an interesting question! I don't think we have enough information yet to answer, but I wouldn't be surprised if we find some benefit for PMDD, premenstrual exacerbation of symptoms, and PMS. This might be related to the anti-inflammatory effects of GLP-1 drugs, improved management of diabete...
What medications do you consider for patients with premenstrual dysphoric disorder who do not respond to SSRIs?
In addition to emphasizing how helpful self-care can be (a little more sleep than usual, exercise, healthy nutrition, including limiting carbs, mindfulness), calcium carbonate 600 mg BID, judicious benzodiazepines, and gabapentin 100-300 mg hs can be helpful. Continuous OCPs can also be very useful....
What is your approach to evaluating Tardive Dyskinesia in nonverbal patients?
Nonverbal patients can still be affected by TD, so if there is a significant functional impact, treatment can still be offered. If a patient is completely unable to communicate, it is difficult to assess for side effects or symptomatic improvement, so the risk-to-benefit analysis would be largely un...
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, ...
How do you approach titration or transitioning to Cobenfy in patients currently on an antipsychotic?
Antipsychotics with significant anticholinergic activity, such as olanzapine and clozapine, can add to the effects of trospium contained in xanomeline-trospium combination. Product labeling reads "Concomitant use of COBENFY with other antimuscarinic drugs that produce anticholinergic adverse reactio...
What is your approach to delayed or inhibited ejaculation related to SSRI sexual dysfunction?
There are several theoretical possibilities that have been suggested over time. Periactin 4mg 30 minutes prior to sex is noted as a possible intervention. I've never seen any benefit from this. Another possibility is to add Wellbutrin at regular dose which allows for additional sympathetic nervous s...
How do you approach treatment-resistant depression and anxiety related to menopause refractory to SSRI/SNRIs and hormone replacement therapy?
First, I try bupropion and have found that the dopaminergic medication is excellent for refractory depression, especially as one ages because dopamine gradually decreases 10% per decade (Berry et al., PMID 27807030). If bupropion doesn't help, then I have used pramipexole quite effectively over the ...
How do you formulate and diagnose patients with chronic psychosis that developed after methamphetamine use but persists after cessation of use?
It may ultimately become schizophrenia that’s been unmasked by the stimulant use. I believe you need six months or maybe three months for a schizophreniform diagnosis, and then after that, it becomes schizophrenia if it meets all the other criteria. I have to check the DSM on the timeline.
What has been your experience with alternative injection sites to the abdomen for improving pain/tolerability with buprenorphine extended release?
I agree with Dr. @Dr. First Last's comments about 1) rotating injection sites on the abdomen, 2) considering alternate sites per the new package insert, and 3) pretreating with lidocaine. In addition, I would recommend considering Brixadi, which has a smaller gauge needle (23G as opposed to a thicke...