Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage cannabinoids (ex: medicinal, recreational) in dermatology?
I use dronabinol 2.5-10 mg qd-tid for recalcitrant pruritus (typically neuropathic or CPUO as an adjunct treatment). Very cheap using GoodRx if not covered by insurance. It’s a scheduled drug, so it requires DEA, but you don’t need a “medical marijuana license,” and it’s very well tolerated outside ...
When do you consider adding an antipsychotic for SSRI-refractory OCD, and which agent do you typically choose first?
There are so many factors that play into my decision-making; it truly is a case-by-case basis. In my opinion, the most common mistake is not adequately titrating the dose of the SSRI. You also need to make sure they are getting high-quality CBT/ERP at least 1x/week, ideally 2x/week for the first mon...
What is your approach to managing sexually inappropriate behaviors in hospitalized patients with psychotic symptoms?
Sexually inappropriate behaviors, commonly abbreviated as ISB in the behavioral and sex offender treatment communities are very often problematic, especially when combined with psychosis. ISB can vary from relatively mild, such as accidental self-exposure by a confused patient, to the very severe, s...
How do you approach patients with fibromyalgia who are reluctant to consider a psychiatric component to their illness but present with clear mood or anxiety symptoms?
Since patients with fibromyalgia (FM) are often stigmatized and worried that clinicians think “it is all in my head,” it is important to discuss FM treatment and mental health referral from a biopsychosocial perspective. This might include introducing concepts such as the pain/depression dyad, centr...
When do you recommend HLA testing prior to prescribing lamotrigine, carbamazepine, or oxcarbazepine to patients of Asian descent?
I never use carbamazepine, given how it’s a pan-inducer and often lowers the level of other medications that may be in the regimen, such as quetiapine and haloperidol, since they are mainly metabolized by CYP3A4.Oxcarbazepine has a 50% reduction in the induction of carbamazepine, so I use that somet...
How do you approach continuation of benzodiazepines in elderly patients with anxiety who have had poor response to other medications?
This is a risk/benefit analysis question, and will be unique for each patient. The biggest danger is making an internal rule that ignores the patient's needs. Many variables come into play: if the person has been on them for years or decades, then it probably causes more harm to discontinue, as they...
What is the role of cognitive training exercises in older patients with short-term memory problems and/or are diagnosed with mild cognitive impairment?
You are correct. The evidence so far is level C - as far as I know. No robust RCTs. Exercise gets a Level B recommendation. You may maximize benefit by offering more supervision (supervised computerized cognitive training), combining with resistance training, and/or increasing frequency. Most effect...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
How do you approach diagnosing suspected early tardive dyskinesia with minimal positive findings on AIMS examination?
Before adding any medications, I generally try to remove any offending medications, like antipsychotics, or meds like stimulants that can lead to tardive tics. One can see TD with SSRI medications, but it is rare. If I suspect TD despite not having a positive AIMS test, I will sometimes have patient...
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...