Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach patients with substance use disorders who require chemotherapy for their cancer?
This is, unfortunately, a common, challenging situation that requires addressing multiple facets of care.The first is having enough mental health support for the patient and having a non-judgmental approach. We're lucky to have embedded clinical psychologists in our oncology clinic at my institution...
How do you approach the use of stimulants in patients with ADHD with previous or current substance use disorders?
I agree with Dr. @Dr. First Last about the use of non stimulants as an important intervention with these patients with the added caveat that Wellbutrin XL is highly abused by crushing it up and snorting it. Even this strategy has its limitations in addressing the issue of ADHD and Substance Use Diso...
What precautions should be taken when discharging a patient from the medical setting on new medication assisted therapy for alcohol use disorder?
Great question. This article absolutely adds to the argument for using medications for alcohol use disorder. The precautions would mostly explain side effects, just as you would for any new medication. A few specific considerations depend on the medication (I'll restrict this to four more common cho...
How do you engage and approach a patient presenting with psychotic symptoms who has demonstrated a pattern of malingering and also has polysubstance use disorder?
This is a nice general summary of some basics, non-judgemental, supportive approach, quiet/low stimulation environment: Mental Health First Aid Guidelines. With regards to malingering and how to approach it, try to determine the real want/need (housing or food insecurity?) and if it is something tha...
What recommendations do you have regarding the use of dronabinol to prevent cannabis withdrawal in an inpatient medical or psychiatric setting?
I routinely use dronabinol in patients who are heavy/daily cannabis users and are having a hard time as inpatients with any degree of withdrawal and cravings. It can be a good anxiolytic as well as antiemetic and orexigenic in this situation. Depending on their preferences, it can be scheduled with ...
How do you manage patients with alcohol use disorder who express interest in moderation rather than full abstinence?
In the past, I would try to engage these patients in complete recovery—AA, etc. Today, having read the literature on harm reduction and perhaps being more experienced and tolerant with age, I engage the patient in healthcare activities like exercise, sleep, and diet, and discuss recovery from alcoho...
How do you approach weaning patients off of buprenorphine?
I have found using injectable extended release buprenorphine (XR-BUP) as a good way to help patients taper off SL buprenorphine in a means much more tolerable than trying to taper SL buprenorphine. We published a case series on this approach (Ritvo et al., PMID 32925232) and subsequently another cas...
Have you incorporated National Acupuncture Detoxification Association (NADA) ear acupuncture into the treatment of substance use disorders?
No, not necessarily. Perhaps on a case-by-case basis, and with patient request, this option is considered. Don’t have evidence-based data to support its use.
When do you use SNRIs or norepinephrine reuptake inhibitors (e.g., atomoxetine) for the treatment of ADHD?
Diversion of stimulants is a concern. However, patients with ADHD symptoms who have a robust response to stimulants are motivated to continue treatment and to ensure compliance. I have not found SNRIs, SSRIs, or bupropion effective for ADHD but agree that they may be indicated for comorbid anxiety a...
What are your preferred methods for QTc calculation for normal, tachycardic and bradycardic heart rates?
This depends on the need for precision. If for clinical purposes, the Fredericia correction formula will suffice and is less sensitive to heart rate distortion than Bazett's. If the goal is to precisely define the QT interval in a clinical trial, such as a thorough QT study of a new chemical entity,...