Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What do you recommend to patients when they are having an acute flare of fibromyalgia symptoms?
Great, this is a really important area and unmet need in the field of fibromyalgia management. Unlike other nociplastic disease states (e.g., migraine), there are no rigorously studied abortive therapies to rapidly treat a flare of centralized pain. Indeed, all the therapies we use for FM are intend...
How do you approach initiating esketamine treatment in older adults with difficult-to-treat depression?
Definitely a tougher crowd to treat, in general, whichever treatment is chosen. All the aforementioned considerations come into play, but it is also important to note that esketamine works well in older patients and should be offered as a treatment if it is appropriate. Regarding preliminary conside...
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...
When do you consider using ketamine to treat depressive symptoms in patients with borderline personality disorder?
It's understandable to exhibit caution when treating patients with borderline personality disorder (BPD) with ketamine. Naturally, questions arise as to the efficacy of the treatment and whether they may experience destabilization while under the influence of the drug. Still, there is no literature ...
How do you treat disruptive mood dysregulation disorder?
DMDD is quite an enigma. The whole concept of irritability, which transcends many diagnoses, is also interesting. DMDD was meant to avoid overdiagnosis of moody disruptive behavior as bipolar. Since many of those kids are not suffering from bipolar disorder, I thought it was a great move. Unfortunat...
When do you select cholinesterase inhibitors vs NMDA-antagonist medications in patients with moderate Alzheimer’s dementia?
Cholinesterase inhibitors should be given to all patients (unless there is a contraindication) with Alzheimer's dementia since this class slows cognitive and functional decline as well as reduces all-cause mortality. Memantine, an NMDA receptor antagonist, is only FDA-approved for moderate to severe...
How do you navigate requests from your employers to see patients for shorter appointment times or less frequently than you feel is clinically indicated?
It takes an hour to get the basic data and an hour to 'really find out what's going on' and to begin to establish some rapport.
What strategy do you find most effective for outpatient induction of buprenorphine in opioid use disorder?
The method for induction of Buprenorphine for OUD needs to be tailored for the specific patient and the environment. The standard induction was introduced during the time when heroin was the most common opioid being used on the streets, as well as diverted prescription narcotics. Also it was mainly ...
How do you weigh the risks of overdose with medications that treat severe mental illness?
Lithium is a double-edged sword… I don’t usually use it for only the anti suicidal properties but if I do, then I prescribe it in weekly dosing. There was a case report from Russia where they used clozapine to poison someone. Besides that, I’m not too worried about a clozapine overdose but lithium i...
Do you treat 45 mg/day as a practical ceiling before switching strategies in a child with ADHD and incomplete methylphenidate response?
This is a very good question, and generally, the guidelines are not clear. In clinical practice, I almost never prescribe more than 45 mg/day of methylphenidate for a patient. Some sources recommend not exceeding 60 mg/day for immediate-release methylphenidate, and others set the limit at 72 mg/day ...