Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you consider using olanzapine/samidorphan?
I prefer to use olanzapine/samidorphan combo in mildly obese patients when I decide to start olanzapine, and the patient does not have the info and skills yet to work on self-care. Unfortunately, there is still some weight gain on this combo, but at least not the usual 20-30 or even more in olanzapi...
How do you differentiate major depressive disorder from baseline functioning in patients with intellectual disabilities?
A general assumption of psychiatry is that people with intellectual disabilities can be afflicted with nearly any of the psychiatric disorders apparent in the general population. However, making the diagnosis of other psychiatric disorders in people with varying degrees of intellectual disability an...
What is your approach to delayed or inhibited ejaculation related to SSRI sexual dysfunction?
There are several theoretical possibilities that have been suggested over time. Periactin 4mg 30 minutes prior to sex is noted as a possible intervention. I've never seen any benefit from this. Another possibility is to add Wellbutrin at regular dose which allows for additional sympathetic nervous s...
What is your approach to augmenting treatment for depressive disorders in those continuing to take a tricyclic antidepressant at baseline due to historical effectiveness?
Depends on the risk of suicidality. If there is any history or any hint of a possibility of it, I do not continue with a TCA. I would augment with a dopamine agonist. I only use TCA to help with multiple comorbidities, such as migraines, insomnia, neuropathic pain, along with depression - knowing I ...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
What is the first intervention you reach for when a caregiver shows signs of burnout?
In these situations, I often spend time understanding the situation, as each situation is unique. Once I have more information regarding the particular situation, I then problem-solve with the caregiver. Interventions may include referrals to Area Agencies on Aging for support, referral for psychoth...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
Which patients are good candidates for transcranial electrical stimulation for the treatment of chronic insomnia?
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that has demonstrated efficacy in the treatment of insomnia in randomized clinical trials, although evidence supporting its long-term effectiveness remains limited. Studies have reported improvements in both subjectiv...
How would you treat psychotic symptoms in a patient with atypical psychotic-induced leukopenia with absolute neutrophil count (ANC) below 500 cells/µL (<0.5 x 10^9 L)?
I have not been faced with that situation except on Clozaril. I will use benzodiazepines initially to control anxiety and reduce the stress with psychotic symptoms. Later, when the white count starts to improve, I will initiate a different drug. Will go slow and check counts often enough not to miss...
How do you decide when and how often to reach out to patients with serious mental illness who are disengaging from care due to psychosocial stressors?
Outreach is always determined on a case-by-case basis, so it's difficult to give a definitive answer on this. Important factors to consider are the person's functional status, potential risk for harm without care, their decision-making ability, and the intensity of stressors. Obviously, those who ar...