Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
Do you prescribe linezolid to patients who are concomitantly on an SSRI?
Yes, cautiously, especially when LZD is the best or only option. Recent Eur J Clin Pharmacol July 2023 meta-analysis involving 84 publications found an observed rate of < .01%; another study Shi et al., PMID 37301313 found a similar rate (1/1743 persons, 0.06%). Holding an SSRI for a day or two prio...
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
When is it useful to test for multiple amyloid-related biomarkers for patients undergoing work-up for cognitive impairment?
If a patient has a presentation consistent with MCI or early dementia due to AD (slow progressive decline, STM loss, no hallucinations, no neuro deficits), I will get an MRI and amyloid blood-based biomarkers. If the goal is just a diagnosis, I stop there. If they are interested in “mab” therapy, I ...
When do you consider referring adolescents with major depressive disorder for TMS?
TMS has gained FDA approval to aged 15 for major depressive disorder refractory to medication. That statement alone has many layers. First, often the mood disorders that are difficult to treat do not necessarily meet criteria for MDD, and this is often because of family concerns and environmental st...
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...
Would you be comfortable using isotretinoin in a female teenage patient who has a history of depression that is now stable but with a prior suicide attempt two years ago?
Yes. There is ample evidence that isotretinoin does not cause depression. In the large Canadian study, there was a slightly negative association with suicide. As the good doctors noted above, using appropriate step therapy, with informed consent (especially regarding pregnancy and birth defects), is...
How reliable do you find it to make the diagnosis of bipolar disorder based on a patient report of prior symptoms or questionnaire and not the actual observation of hypo/mania on the exam?
I agree that direct observation is always nice, but we certainly don't want to wait for a manic episode to determine the correct diagnosis. I find that by asking lots of detailed questions, most people who have experienced and manic episode can report enough history to correctly. Identify the episod...
How do you approach the management of mild to moderate tics induced by stimulants in children?
If dose reduction or medication switch is not possible, first-line treatment includes adding an alpha agonist like guanfacine or clonidine. I prefer guanfacine as clonidine is more sedating and less tolerated by kids. CBIT (Comprehensive Behavioral Interventions for Tics) would be great but hard to ...
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...