Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
How do you respond to early refill requests for stimulants in stable patients who report lost or stolen medication?
I do not refill stimulants when they are reported lost or stolen. When starting a treatment course of stimulants with a patient, I review a brief list of instructions and expectations. For stimulants, this includes that it is their responsibility to store and protect their medication from theft or l...
How do you define treatment-resistant depression in your practice?
Well, technically, treatment-resistant depression is defined as no meaningful response after at least two trials of antidepressants at therapeutic doses and durations (≥8 weeks). The first step is to rule out inadequate dosing (try to reach the max dose), poor adherence, and medical comorbidities th...
How do you approach the treatment of anxiety disorders in children with a significantly family history of bipolar disorder?
First, I always question the validity of a family history of bipolar disorder and clarify as best as possible bipolar 1 vs. 2. Nine times out of ten, it is "mood swings" that with further clarification were never formally diagnosed and were anger outbursts/irritability. If there is bona fide bipola...
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
How do you approach the use and titration of Cobenfy in patients with treatment refractory schizophrenia not responding to clozapine?
This has to be managed carefully, given the anticholinergic effects.
When do you consider antipsychotic augmentation of antidepressants for PTSD?
Traditionally, antipsychotic augmentation of antidepressants was reserved for patients with high levels of paranoia or frank psychosis. The VA Cooperative Study of Risperidone also found that antipsychotic augmentation could be helpful for PTSD-related insomnia. The recent brexpiprazole study (Davis...
How do you counsel patients with mild to moderate depression interested in using St. John's Wort?
Although this is used in parts of Europe, there it is considered a pharmaceutical and has higher standards for dose and potency. Here, as it is a health food product, different batches may require different doses of the pill due to differences in potency. There is some data to suggest that the combi...
What strategies do you find most effective at managing opioid withdrawal in hospitalized patients who are not interested in MAT?
There was a time when the majority of patients did not want maintenance on an opioid agonist (methadone), and we did not have partial agonists (buprenorphine) available. This underlines how far we have come in the last 15 or so years. At that time, all we did was use the alpha2 noradrenergic agonist...
How do you approach the titration of Ambien (zolpidem) to treat catatonia?
I have no experience of using Ambien for catatonia, but have read an article from the NIH library, which shows a promising alternative when lorazepam does not work and ECT is not available readily. These are only case reports. Research is needed.