Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your therapeutic approach to strengthening the therapeutic alliance and improving medication acceptance/adherence in patients with delusional disorder?
The Carlat Report just had an article on Xavier F Amador, PHD, who specializes in working with people who are unaware of having a psychotic condition and so reluctant to take medication. His book: I am Not Sick, I Don't Need Help, links anosognosia, the failure to recognize a part of the self that o...
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.
What considerations do you take regarding using valproic acid in men who are hoping to conceive with a partner?
A recent cohort study (Meng et al., PMID 41733407) utilizing national databases in Norway and Taiwan examined associations between exposure to paternal valproate monotherapy during the 90 days preceding conception and incidence of neurodevelopmental disorders (NDDs) among offspring after at least 6 ...
When do you attribute tremors to lamotrigine?
Not a side effect of LTG, but tremors are common and patients love to attribute everything to medications.
How do you manage obsessive-compulsive symptoms secondary to clozapine?
You have to find a good balance, which can be very challenging if the psychosis and OCD are prominent. Clozapine exacerbates OCD the most out of any antipsychotic. You can use Luvox to help boost clozapine levels and decrease norclozapine levels, which is the main culprit of metabolic side effects; ...
When do you consider using dextromethorphan–bupropion for the treatment of depression?
The data support a rapid antidepressant effect given the NMDA activity that is different than monoamine activity of all other antidepressants. Within a week, many patients I treat notice a benefit and this continues to improve for several weeks. The general guidelines would suggest Auvelity be a sec...
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...
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 manage transient post-ECT symptoms like irritability, tearfulness, or panic attacks?
Transient emotional symptoms after ECT are fairly common, particularly in the first 30-90 minutes after treatment and during the recovery period. Although the literature focuses more on confusion, headache, and myalgias, many experienced ECT psychiatrists report seeing brief episodes of irritability...
How do you handle requests from patients to complete medical paperwork that falls outside your scope of practice when they cannot access their other clinicians?
These requests are relatively common and can come from the patient, a healthcare institution, or another institution, such as an insurance company or school. A subtype is the forensic document, which can come from an attorney, a local state, or a federal agency. At times, law enforcement agencies ma...