Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How have you gone about implementing TMS in your practice or institution?
For me, the hardest issues with TMS are getting insurance to approve it and the time it takes from a patient’s perspective to see a benefit.When I first invested in the TMS machine, I calculated it could take up to 3 years to pay off the equipment cost. In actuality, I was able to recoup the initial...
How do you counsel patients on cannabis use for PTSD?
In general, I recommend stopping cannabis. The large stratification study from the VA (sorry, only one cup of coffee and late night last night, so blanking on the authors or year) looking at patients who never used (19,000), chronically used before and during 3 months of treatment (2000), picked up ...
What is your approach to patients requesting prescription sleep aids, such as trazodone, quetiapine, or olanzapine, at discharge after they have found them beneficial during a prolonged hospitalization?
I don't see the harm in continuing a patient on trazodone or melatonin on discharge until they see their PCP, if they were benefiting from it in the hospital. For example, if you see a dementia patient with sundowning and have helped them sleep peacefully with trazodone, melatonin, or low-dose Remer...
What resources/ancillary staff do you utilize for school re-entry after cancer treatment to decrease anxiety, improve self-confidence, and support emotional functioning?
Facilitating school re-entry for children and adolescents undergoing cancer treatment is an important component of comprehensive care. Maintaining engagement in school can help preserve a sense of normalcy and mitigate feelings of isolation and loneliness. However, the transition back to school may ...
How do you transition severely agitated ICU patients off a dexmedetomidine infusion when it is being used primarily for psychiatric agitation?
Even if initial agitation is felt to be psychiatric, it is important to remember (and remind involved teams) that following intubation and sedation in the ICU, rebound agitation as dexmedetomidine is weaned may have become multifactorial. As such, interventions such as monitoring for contribution fr...
When do you consider starting an antidepressant without a mood stabilizer in a patient with a historical diagnosis of bipolar II disorder who has not had hypomanic episodes in many years?
I happen to have a patient just like this now on my inpatient service. One of the problems we run into often is uncertainty around the validity of the bipolar spectrum in the first place. We see so much complicated trauma, maladaptive behaviors, and disordered personality structures that periods of ...
How do you approach stimulant prescribing for ADHD when a patient has previously reported palpitations with stimulants but has a normal EKG off medication?
Get a cardiology consult and get a certificate about stimulant safety before initiating stimulants.
How do you manage withdrawal symptoms after stimulant discontinuation?
I have not witnessed bradycardia as a withdrawal symptom of stimulants at therapeutic dosages, although this is common with misuse/SUD. I have noticed increased behavioral and mood symptoms due to stimulant discontinuation, which may be related to shortages. I simply use whatever formulation is avai...
When do you use extended-release buprenorphine instead of daily formulations?
Extended-release buprenorphine (e.g., Sublocade, Brixadi) can be a good option for patients who have trouble staying stable on daily sublingual doses, especially those with adherence challenges, ongoing exposure to high-risk opioids such as fentanyl, or concerns about safety and diversion. Weimer et...
How do you evaluate and manage patients who report vivid, distressing dreams or “epic dreaming” that disrupt sleep quality?
Nicotine or nicotine replacement being used? (Very common cause) Varenicline (Chantix) for smoking cessation being used? (Known effect) Melatonin being used? (Possible, more likely with high/excessive doses) Recent reduction or cessation of an antidepressant resulting in REM rebound? (Known to cause...