Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
How do you counsel breastfeeding parents with postpartum depression when sleep deprivation appears to be worsening mood symptoms?
My position is that breastfeeding is a sometimes difficult practical issue, not a medical or moral imperative. I try to normalize the difficulties of breastfeeding, based on my own experience and that of my daughters and sisters, countering the exploitation of anxiety around this issue with problem-...
How do you manage expectations around response time and durability of benefit in patients starting TMS?
Re: response time, I tell patients it is typical to not notice a lot of change in the first few weeks. Sometimes the clinician will observe brightening of affect earlier, but the patient him/herself often does not notice a whole lot. I use the 'going to the gym' analogy... a few days will not yield ...
When have you found hypnosis helpful for parasomnia?
Usually, when treating NREM parasomnias such as sleep terrors and sleepwalking, the patient has to practice the techniques every night in addition to removing identified triggers.
How do you counsel patients who want to understand why sublingual cyclobenzaprine works to relieve their fibromyalgia pain and other related symptoms?
I like to set the stage with patients and make sure they clearly understand the link between sleep disruption and pain sensitivity, particularly in the context of central pain and fibromyalgia. One of my rheumatology attendings during fellowship used to explain this using classic sleep research from...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
What clinical factors guide your decision about if and when to restart antipsychotic medications in patients with primary psychotic disorders recovering from catatonia after stabilization with benzodiazepines or ECT?
The American Psychiatric Association's catatonia workgroup recently published an excellent Resource Document for Catatonia.In this document, they discuss some relevant points on pages 25 - 27: There is a longstanding history of using antipsychotics in catatonia, with available reports on the use of ...
What is your approach to using clonidine for anxiety?
It definitely helps in patients with autism with anxiety, 0.1 mg po bid but not my first line because of the blood pressure drop or rebound. I don’t use it as a first line for anxiety, as I haven’t seen any improvement if it’s just used for anxiety. Strattera has some evidence for anxiety in autism,...
How do you incorporate rating scales such as the PHQ-9 into your treatment of major depressive disorder?
My practice has evolved (more therapy now), but for 20+ years, I administered the PHQ-9 and the GAD-7 at every visit for every patient. During those years, everyone was on some form of medication, and it felt relevant to see how they were responding. Also, occasionally someone would have worse numbe...
How do you approach managing perioperative anxiety in Mohs patients?
Great question. Music, stress balls, having your team engage in conversations with the patient, and other distraction techniques are helpful. Some patients may need medications such as Halcion to help with anxiety but this should be given after the patient signs consent and has a verified driver aft...