Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach liver function testing and monitoring when using xanomeline/tropsium (Cobenfy)?
Good question, as it’s a newer medication on the market. I prefer a CMP as a baseline but since I’ve come across the first reported case of neutropenia with Cobenfy, I would suggest getting a CBC weekly, but move to monthly after a few CBCs, and when getting the CBC with diff, get a CMP. It can’t hu...
How do you approach patient requests for medical time away from work or other accommodations (such as disability paperwork) when the patients have mild-moderate symptoms being managed in the outpatient setting?
This is a very important question as clinicians are often requested to provide certain assertions based on their role as the medical provider. In reviewing this, there are several areas to keep in mind: First, if you are the provider and are the one with the knowledge, then you should provide the r...
How do you manage anxious children who are somatically focused and do not tolerate SSRIs?
Treatment of an anxious child ideally involves a holistic bio-psycho-sociocultural approach to understand the nature and underlying reasons for the anxiety, and importantly, the family's response and accommodations to their child's anxiety. So individual CBT-focused therapy can be very helpful, but ...
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
How do you approach agitation management, especially the use of neuroleptics in hospitalized patients with a prolonged QTc?
First, I'd wonder how long the QTc actually is. Especially in tachycardic and bradycardic situations (let alone non-sinus rhythms), hand calculation (e.g. via the hodges formula) is advised since the electronic reading is often off. Also, textbook-prolonged and prolongation that would indicate conce...
At what point would you recommend initiating psychotherapy or psychotropic medications to manage mood and anxiety symptoms following a new oncology diagnosis in pediatric patients?
Perhaps the most important piece to this question is missing, and that is that more history is required to determine what to do with a recently diagnosed cancer patient. What was the patient’s psychiatric status pre-cancer? If the patient had undiagnosed mental health problems–anxiety or depressio...
What interventions do you recommend for preschool-aged children exposed to severe trauma (ex. sexual assault) but not displaying any observable signs of PTSD?
I would be curious as to when the "assault" occurred in relation to the child being evaluated? When one says that there are no PTSD symptoms, are they using the under-6 criteria? PTSD symptoms are not the only response to an assault; children are more likely to demonstrate distress behaviorally, su...
Do you find consumer grade wrist actigraphy useful in measuring sleep quality and duration?
Consumer wearables are advancing quickly, and there is a lot of variation in their performance, particularly in those with sleep disorders. Unfortunately, there is a wide variation in the performance of devices, even ones using the same signals to calculate sleep/wake. Additionally, orthosomnia is a...
What are your concerns regarding long term stimulant use in geriatric patients with ADHD?
I agree with @Dr. First Last; however, I had a patient in their mid-70s with small vessel disease (Parkinsonism) who had a gait disturbance, cognitive, and organizational problems. He was a lawyer who was trying to close his practice, and I gave him 10-20 mg of dextroamphetamine ER. It helped him co...
What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?
In our outpatient substance use disorder practice, we tend to use lisdexamphetamine (Vyvanse) at fairly high doses off-label for patients with meth withdrawal. We establish a buddy system preferably with someone who lives with them, provide Suicide hotline phone number, describe reasons to transport...