Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
How should psychotherapy techniques for patients with autism spectrum disorder be adjusted, if at all?
The answer depends, at least in part, on the level of ASD with which the patient presents. Psychotherapy can be very useful for patients with Level 1 ASD, but some individuals with Level 1 ASD are more capable of benefiting from therapy than others. In general, using a more structured approach, allo...
How do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...
What doses of lithium have you found effective in reducing suicidal ideation?
For depression augmentation in patients who have non-bipolar states, I generally use 150-450 mg (low-dose lithium). The blood levels usually range below therapeutic for bipolar, but the low-dose lithium can help reduce SI without too many side effects. I still watch for issues of thyroid and kidney ...
How do you view the risk of tardive dysinesia and other side effects in your female patients with treatment-resistant depression who are stable on an atypical antipsychotic?
Superb question, and it also applies to bipolar disorder, which is even more challenging in this patient population. I like Dr. @Dr. First Last's answer, always a risk/benefit analysis. Probably what you are already doing is my guess, since you are asking this question. Make sure you are doing consi...
When do you consider the use of lumateperone to treat schizophrenia spectrum disorders?
It is obscene that these drugs cost $1,400-$1,800/month retail.
How do you approach disposition planning when a patient makes homicidal threats on presentation to the emergency department but later recants?
Tarasoff rules. Tarasoff v. Regents of the University of California The ER department remains in the purview of all medicine in the USA, in my opinion. “How do you approach” is the same regardless of the setting. The thought of the clinician remains superordinate. Is this really a question? Recant.....
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...
How do you approach patients who present repeatedly to the ED with suicidal ideation but no clear acute change in risk?
If a young patient presents repeatedly to the ED with SI, even if there is no change in acute risk, it is an indication that whatever is being put in place is not working well enough to support the patient, and/or a communication of the young patient's distress. This warrants a careful assessment of...
When do you consider using benzodiazepines to treat insomnia in patients with acute mania?
In acute mania in younger patients, benzodiazepines can be a very helpful adjunct to mood stabilizers when they are not able to control the hyperactivity and insomnia with mood stabilizers alone. In younger patients, I will go with longer-acting benzodiazepines, and in shorter-acting ones for older ...