Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What has been your experience with alternative injection sites to the abdomen for improving pain/tolerability with buprenorphine extended release?
I agree with Dr. @Dr. First Last's comments about 1) rotating injection sites on the abdomen, 2) considering alternate sites per the new package insert, and 3) pretreating with lidocaine. In addition, I would recommend considering Brixadi, which has a smaller gauge needle (23G as opposed to a thicke...
How do you counsel patients when they ask whether the SSRI or SNRI antidepressant you have recommended will result in weight gain?
This recent study on antidepressant-associated weight gain has generated a lot of interest and press, and can be a helpful starting point: Petimar et al., PMID 38950403.As with all studies, it has its limitations, but highlights that many people will experience minimal-modest weight change on antide...
When do you consider using ketamine to treat depressive symptoms in patients with borderline personality disorder?
It's understandable to exhibit caution when treating patients with borderline personality disorder (BPD) with ketamine. Naturally, questions arise as to the efficacy of the treatment and whether they may experience destabilization while under the influence of the drug. Still, there is no literature ...
What treatments have you found to be most effective in patients with a schizo-obsessive disorder?
This is a good question, as this happens in about 30% of our patients who have this. It depends on the severity of the psychosis versus OCD. Sometimes it’s hard to tease out are we're dealing with psychosis or the OCD is so severe it comes across as psychosis. That’s the first step. Then, as I said ...
When do you consider the use of an MAOI in treatment-resistant major depressive disorder?
MAOIs can be great in treatment-resistant depression, but after you explain how there might need to be some dietary restrictions, patients generally refrain from wanting to try them. To be frank, the dietary restrictions are overblown (A concise guide to monoamine oxidase inhibitors). There are 2 pa...
Do you screen for MTHFR polymorphisms in your patients with treatment-resistant depression?
In the trial by Papakostas et al., PMID 23212058, we have shown that adjunctive L-methylfolate at 15 mg/day had significantly greater efficacy compared with continued SSRI therapy plus placebo on both primary outcome measures (response rate and degree of change in depression symptom score) and two s...
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
How do you approach a treatment relationship with a patient who is non-adherent to recommendations and also is not interested in transfer to another practitioner?
This situation superficially forces a provider to sit with frustration and perhaps resentment versus skirt the issue of abandonment. Some would (or would wish to) choose the latter and be ethically content to follow rules about providing referral information and a "buffer" period of continued care w...
How do you approach liver function testing and monitoring when using xanomeline/tropsium (Cobenfy)?
Good question, as it’s a newer medication on the market. I prefer a CMP as a baseline but since I’ve come across the first reported case of neutropenia with Cobenfy, I would suggest getting a CBC weekly, but move to monthly after a few CBCs, and when getting the CBC with diff, get a CMP. It can’t hu...
How do you approach patient requests for medical time away from work or other accommodations (such as disability paperwork) when the patients have mild-moderate symptoms being managed in the outpatient setting?
This is a very important question as clinicians are often requested to provide certain assertions based on their role as the medical provider. In reviewing this, there are several areas to keep in mind: First, if you are the provider and are the one with the knowledge, then you should provide the r...