Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach continued prescribing of benzodiazepines when a patient who is already prescribed benzodiazepines reports concurrent illicit benzodiazepine use?
The management of patients who are prescribed benzodiazepines while concurrently using illicit benzodiazepines has become increasingly complex, particularly with the growing prevalence of synthetic benzodiazepine analogs within the illicit drug supply. Over the past decade, benzodiazepine prescribin...
In a frail older adult with depression unresponsive to two SSRI trials, what's your next step in management?
This is certainly a longer and nuanced conversation. Depends on the intensity of symptoms. Ensuring the diagnosis is accurate, reviewing the role of co-morbid cognitive disorders, organic issues masquerading as depression, and so on. Augmentation of an SSRI, e.g., mirtazapine, stimulating medication...
After remission from a first episode of psychosis how long do you continue antipsychotic treatment before attempting taper or discontinuation?
I don't think this is a one-size-fits-all question. This will depend on a number of factors. Probably most important is the client's attitude toward medication and their experience with it. Those who have done well with medication and have had no problems with side effects may be more comfortable co...
When is the best time to get a valproate level if a patient is taking Depakote DR once daily?
Levels should be obtained at steady state - which is 5 half lives. For ER formulation, figure about 5 days and it should be a trough level (immediately before the next dose).
When do you recommend neuropsychological testing in adults being evaluated for ADHD?
We should consider “testing” only when our main tool of diagnosis, a thorough psychiatric interview, history, and physical (mental status exam), demands more data for a diagnosis. Demanding neuropsych testing would be akin to relying more on an MRI than on a clinical assessment for a headache diagno...
For pediatric patients who are being successfully treated for migraines with a TCA such as amitriptyline, would you consider starting an additional SSRI or SNRI for mood/anxiety symptoms, given the risk of serotonin syndrome?
My first inclination would be to just increase the TCA that is already being used and bring it up to therapeutic levels for antidepressant and anxiolytic effects. The TCAs are very effective antidepressants but come with a wider array of side effects, which makes compliance a bigger issue with these...
How do you manage a patient with severe mental illness whose psychiatric symptoms worsen significantly during inpatient cancer treatment?
There are many issues to keep in mind, such as not all "mental illness" is necessarily a primary psychiatric disorder. Below are some common problems: For management of steroid-induced psychosis/mania, which typically has an onset within 3–4 days with risk >80 mg/day prednisolone equivalent. I would...
How do you approach the use of SSRIs to treat bipolar depression?
I don't consider antidepressants first-line treatment for my patients with bipolar disorder. I have all my bipolar patients on a mood stabilizer, usually lithium or lamotrigine. I also tend to add an antipsychotic to the mood stabilization regimen for the majority of my patients, usually generic for...
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
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...