Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How have you incorporated Eye Movement Desensitization and Reprocessing (EMDR) into your outpatient psychiatric practice?
Training is formal and takes one week, and the training I had was truly excellent and experiential. The EMDRIA website has a list of trainers and trainings. I have found EMDR to be a powerful modality that rapidly clears the negative emotions related to past traumatic or unpleasant events. I use it ...
Have you used cannabinoid-based products for insomnia?
No, but patients report it helps. I don't encourage it due to a lack of research supporting long-term positive effects.
Do you find that hydroxyzine worsens cognitive symptoms in patients who are already susceptible to cognitive impairment?
Hydroxyzine should not have a direct negative effect on cognition. For decades after its inception, it was lopped in with Benadryl in terms of its receptor binding affinity profile and is listed in several anticholinergic burden scales as being anticholinergic. Similar to the child’s game ‘telephone...
What are your experiences with lithium target levels in the maintenance of bipolar 2 disorder?
I prefer maintenance lithium levels at the 0.7-0.8 range, because I wish to provide a more rigorous test of lithium's ability to prevent recurrence in each BPII patient.
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
Have you had success using lumateperone for behavioral symptoms in autism spectrum disorder?
While I have used this medicine successfully as an adjunct to an antidepressant or as a first-line treatment for bipolar disorder. I’ve never used it in autism spectrum behavioral management. In my experience, it is less sedating than Seroquel, so not as effective at helping people sleep.
What medications do you consider for adjunct treatment of conduct disorder?
This question is very complicated, not least because the assumption that comorbid disorders are being appropriately addressed also assumes that pharmacotherapy is underway. It is tricky to suggest a medicine treatment for conduct disorder without incorporating the medicine treatment for any comorbid...
What is your strategy for discontinuing benzodiazepines in patients with PTSD?
As always, remember that the person has developed habituation and dependency with subsequent definite withdrawal. In our clinic at the U of Miami, the protocol is the reduction, depending on the amount of dependency, of about 10 to 15% per month, sometimes requiring a compounding pharmacy. If you go...
How do you manage patients who send hostile or overly frequent messages through online patient portals in outpatient psychiatry?
This is a complicated yet important topic that should consider boundaries, diagnosis, threat assessment, and termination. Starting with boundaries, I think it is important for the clinician to establish the boundaries that they are comfortable with and share that information with the patient, all wh...
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...