Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you assess and adjust treatment in patients who develops hypothyroidism after being on lithium for several years?
It depends on whether the patient is symptomatic. If not, careful monitoring is all that is needed. If there are significant symptoms, treatment with levothyroxine would be needed. Continued use of lithium is appropriate if it has been effective over time.
How do you approach the use of SSRIs to treat bipolar depression?
I don't consider antidepressants first-line treatment for my patients with bipolar disorder. I have all my bipolar patients on a mood stabilizer, usually lithium or lamotrigine. I also tend to add an antipsychotic to the mood stabilization regimen for the majority of my patients, usually generic for...
What is your experience in the efficacy of vortioxetine for treating anxiety disorders?
Although vortioxetine (currently branded as Trintellix in the USA) is only FDA-approved for the treatment of Major Depressive Disorder, many of the SSRI medications can be used off-label for anxiety disorders, panic disorder, or OCD. Clinical studies often have mixed results, though. Because it has ...
When do you consider lithium for early intervention in those identified to be at risk for bipolar disorder?
Lithium is the preferred first-line agent for bipolar disorder. It offers patients the potential for as close to a cure (restituo ad integrum) as you can get in psychiatry. For this case, I would initiate a 150 mg dose, and potentially build to a low-moderate dose (300-450 qhs) and watch and wait ov...
Other than clozapine, what antipsychotics do you use in a manic or psychotic patient with TD?
Lumateperone is quite all right with minimal D2 involvement. But don't forget the blocking of VMT.
How do you use lithium levels to adjust treatment during mania?
If someone is getting manic, the mania in itself reduces lithium levels. You need for a period of about 6 weeks maintain a level close to 1 in contrast to a maintenance level of 0.75. I would, of course, use the appropriate antipsychotic to help during this period. If the patient has been Li respons...
How do you counsel patients who are interested in dietary approaches for managing major depressive disorder?
In integrative medicine literature, there is some evidence that following an anti-inflammatory diet can improve mood symptoms, including MDD. I imagine this would be a good place to start, and certainly, keto diets are considerably less inflammatory than sugar-based diets with high levels of simple ...
When is the best time to get a valproate level if a patient is taking Depakote DR once daily?
Levels should be obtained at steady state - which is 5 half lives. For ER formulation, figure about 5 days and it should be a trough level (immediately before the next dose).
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
How do you address non-adherence to medical treatment in adolescent and young adult oncology patients due to mental illness such as depression?
The best answer, I think, is to obtain a thorough child psychiatric evaluation. Noncompliance may arise from a number of different issues, some of which may relate to major mental illnesses such as major depression or anxiety disorders, or more cognitively based concerns such as ADHD or executive fu...