Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you discuss sexual and gender identity-related anxiety with teens when family dynamics are rigid or culturally conservative?
First and foremost is safety. Never put children or teens in danger by hostile family or neighbors. In other words, don’t out them or encourage them to out themselves if they don’t feel safe doing so. You never know how people around them might react. That means be careful with your documentation, t...
How do you manage ARFID in children encountered in your practice?
ARFID is a fairly new disorder, having been added to the DSM in 2013. Treatment somewhat depends on the type of ARFID with which the patient presents, although there are shared treatment elements regardless of type. Variants include Avoidant type, which usually revolves around sensory issues related...
What is your threshold for writing disability letters for patients with personality disorders?
I don't believe it's appropriate to have a threshold. Patients with personality disorders are often stigmatized and assumed to be manipulative or malingering. The criteria for writing a disability letter should be "Is the patient's disorder such that they are unable to work?" Assessing their recent ...
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
Is there a potential role for GLP-1 receptor agonists in the management of premenstrual dysphoric disorder?
This is an interesting question! I don't think we have enough information yet to answer, but I wouldn't be surprised if we find some benefit for PMDD, premenstrual exacerbation of symptoms, and PMS. This might be related to the anti-inflammatory effects of GLP-1 drugs, improved management of diabete...
What is your approach to evaluating Tardive Dyskinesia in nonverbal patients?
Nonverbal patients can still be affected by TD, so if there is a significant functional impact, treatment can still be offered. If a patient is completely unable to communicate, it is difficult to assess for side effects or symptomatic improvement, so the risk-to-benefit analysis would be largely un...
How do you approach titration or transitioning to Cobenfy in patients currently on an antipsychotic?
Antipsychotics with significant anticholinergic activity, such as olanzapine and clozapine, can add to the effects of trospium contained in xanomeline-trospium combination. Product labeling reads "Concomitant use of COBENFY with other antimuscarinic drugs that produce anticholinergic adverse reactio...
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...
How do you approach treatment-resistant depression and anxiety related to menopause refractory to SSRI/SNRIs and hormone replacement therapy?
First, I try bupropion and have found that the dopaminergic medication is excellent for refractory depression, especially as one ages because dopamine gradually decreases 10% per decade (Berry et al., PMID 27807030). If bupropion doesn't help, then I have used pramipexole quite effectively over the ...