Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How does comorbid epilepsy influence your decision on antipsychotic medications?
In general, epilepsy is not a contraindication to the use of antipsychotic medications if they are needed despite the known risk of lowering the seizure threshold. In general, the risk of seizures for most antipsychotics is low, though some antipsychotics, such as clozapine, olanzapine, and quetiapi...
How do you monitor and discuss the sexual side effects of SSRIs with adolescents?
Much of this depends on the individual adolescent. During my initial evaluation, I typically obtain a confidential sexual/relationship history with the adolescent. When completing an informed consent with a teen, I will refer back to this history and ask if anything has changed. I'll then frame the ...
How do you approach initiating esketamine treatment in older adults with difficult-to-treat depression?
Definitely a tougher crowd to treat, in general, whichever treatment is chosen. All the aforementioned considerations come into play, but it is also important to note that esketamine works well in older patients and should be offered as a treatment if it is appropriate. Regarding preliminary conside...
How have you approached monitoring for severe side effects of ketamine treatments in the treatment of depression?
So... I'd say I'd never seen such severe side effects in my patients, and partially this is because ketamine infusions, done according to the expert guidelines (we use APA expert guidelines), are quite safe. We absolutely get a medical workup on every single patient, and we repeat the same workup on...
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 ...
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...
How do you navigate requests from your employers to see patients for shorter appointment times or less frequently than you feel is clinically indicated?
It takes an hour to get the basic data and an hour to 'really find out what's going on' and to begin to establish some rapport.
How do you weigh the risks of overdose with medications that treat severe mental illness?
Lithium is a double-edged sword… I don’t usually use it for only the anti suicidal properties but if I do, then I prescribe it in weekly dosing. There was a case report from Russia where they used clozapine to poison someone. Besides that, I’m not too worried about a clozapine overdose but lithium i...
Do you treat 45 mg/day as a practical ceiling before switching strategies in a child with ADHD and incomplete methylphenidate response?
This is a very good question, and generally, the guidelines are not clear. In clinical practice, I almost never prescribe more than 45 mg/day of methylphenidate for a patient. Some sources recommend not exceeding 60 mg/day for immediate-release methylphenidate, and others set the limit at 72 mg/day ...
How do you approach the evaluation and treatment of insomnia in children?
The evaluation and treatment of insomnia in children requires a structured assessment of sleep patterns, contributing medical or behavioral factors, and the implementation of primarily behavioral interventions, with selective use of pharmacologic treatments. Identify Sleep Complaint: Difficulty fall...