Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What policies do you take regarding legalized recreational marijuana or medical marijuana use in transplant patients?
The use of THC and CBD is becoming an increasingly important topic in solid organ transplantation. Recent survey data has demonstrated that daily cannabis use is higher than daily alcohol use in the U.S. (Caulkins, PMID 38775461).Certainly, the legalization of THC use in many states has led to consi...
When do you select cholinesterase inhibitors vs NMDA-antagonist medications in patients with moderate Alzheimer’s dementia?
Cholinesterase inhibitors should be given to all patients (unless there is a contraindication) with Alzheimer's dementia since this class slows cognitive and functional decline as well as reduces all-cause mortality. Memantine, an NMDA receptor antagonist, is only FDA-approved for moderate to severe...
When do you consider using phenobarbital over symptom-driven alcohol withdrawal protocols for patients at low-to-moderate risk of withdrawal complications?
While traditional frameworks often reference "low" or "moderate" risk for alcohol withdrawal complications, in clinical practice we find it more useful to focus on the treatment setting and validated predictors of severe withdrawal rather than subjective risk labels. Phenobarbital is increasingly us...
How do you decide whether to start MAT for opioid use disorder during hospitalization?
There are several considerations when approaching patients about MOUD. In general, every patient should be offered MOUD during their hospitalization because every admission represents an opportunity towards substance recovery. With that said, I don’t entangle substance use treatment with their medic...
What strategies have you found helpful to manage SSRI associated night sweats?
Reduced dose to the lowest effective dose. Gabapentin can be used off-label for hyperhidrosis and vasomotor symptoms of menopause. I had one patient on an SSRI for GAD and found the gabapentin helpful enough for anxiety that he tapered off the SSRI. If it is just night sweats, you can do a nightly ...
In a woman with bipolar disorder with a menstrual component would lamotrigine itself worsen the condition given that it interacts with prescribed estrogen?
Very unlikely. Estrogen can cause a lowering of the Lamictal serum levels and not vice versa. So, if a patient on Lamictal is put on an estrogen product, there may be a need to increase the dose of Lamictal.
What parameters do you follow to avoid rebound effects when using clonidine only for nightly or daily as-needed indications?
I use a fair amount of clonidine in my practice, and I haven't found any rebound blood pressure effects for people who take clonidine nightly or for PRN use. In fact, I've stopped routine practice of checking blood pressure for those who are not taking a standing daily dose. I worry about rebound mo...
How do you approach managing clozapine in patients who are critically ill?
With COVID-19 disproportionately affecting those with mental illness we found an increasing number of medical admissions for those on clozapine. There are multiple domains of concern for those on clozapine who are medically ill. Clozapine levels have been shown to potentially double during periods o...
How do you weigh risks/benefits when referring child and adolescent patients for ECT?
I want to begin with a disclosure: I do not personally treat children with ECT in my practice. However, in a prior academic setting where ECT was performed for adults, I was occasionally asked to evaluate adolescents being considered for treatment by the adult ECT service. When thinking about referr...
When do you start pharmacotherapy for PTSD in children?
The only medications to be used are to address sleep disturbance and nightmares. Poor sleep has been shown to increase PTSS. So prazosin and, on occasion, clonidine should be used. And they should be used as early as possible. SSRIs are generally not that effective and should only be considered if t...