Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Do you change your approach with medications for cannabis induced psychosis or mania?
I usually let it go for a day, and if there is improvement, then I don't initiate treatment but if on the second day and no improvement, then I usually start an antipsychotic as I would if I were treating a primary psychotic disorder aka based on metabolic profile and age.
Do you still consider changing atypical antipsychotics that are working well in children undergoing puberty if the prolactin levels are high but there are no symptoms of drug-induced hyperprolactinemia?
I consider the risk of osteoporosis if I believe it may be used long-term, even if asymptomatic. Typically, I warn parents of the risk but continue the medication if the prolactin is only mildly elevated. I find it rare to find an adult patient who is taking the same drugs they did in adolescence. L...
How do you counsel patients on lithium about NSAID use?
I recommend not using NSAIDs altogether, since there are so many variables to consider if the patient is to remain safe. The patient needs to be highly aware and knowledgeable about their medications, medical problems, age, baseline labs, etc. There are not very many patients like that.
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...
How do you manage daytime somnolence without a clear cause?
One of the newer agents for wakefulness-promoting agents is Sunosi, which has a higher affinity for DAT and NET compared to any other agent (Wellbutrin, Provigil, Nuvigil, Adderall).
What work up do you pursue for a thorough evaluation in patients that present with a potential diagnosis of dermatitis artefacta?
I have found dermatologic complaints some of the most challenging in my psychiatric practice. Dermatitis artefacta (DA) occurs when an individual produces self-inflicted skin lesions in order to assume the sick role, making it a type of factious disorder. When evaluating a patient with suspected DA,...
When do you consider the use of N-acetylcysteine (NAC) in patients with trichotillomania?
Great question! NAC comes up frequently in clinical discussions of trichotillomania, and it's worth being clear-eyed about what we actually know. NAC restores extrasynaptic glutamate homeostasis via the cystine-glutamate antiporter (system Xc⁻), which increases tonic activation of presynaptic mGluR2...
What is your diagnostic approach to patients presenting for ADHD concerns when you suspect untreated sleep apnea?
When discussing a potential ADHD diagnosis with my patients (of note, I only treat adults), I always discuss sleep patterns and sleep hygiene/CBT-I techniques (and recommend stopping any THC usage). I also refer patients with suspected sleep apnea for a sleep study. Some ADHD symptoms may solely be ...
How long do you continue benzodiazepines in patients who have recovered from catatonia?
As others have already responded, it is case-dependent. In an otherwise healthy patient whose underlying medical or psychiatric condition causing catatonia had stabilized, there is likely a way to gradually taper off benzodiazepines without a risk of relapse.However there are other cases that are mo...
When and how do you approach prescribing viloxazine for patients with ADHD?
Viloxazine is a potent inhibitor of CYP1A2 and a weak inhibitor of CYP2D6 and CYP3A4. It should never be used within 2 weeks of an MAOI. I use significant caution when prescribing it with other psychotropic medications, as it can raise the levels of multiple other agents, including aripiprazole, dex...