Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
For pediatric patients who are being successfully treated for migraines with a TCA such as amitriptyline, would you consider starting an additional SSRI or SNRI for mood/anxiety symptoms, given the risk of serotonin syndrome?
My first inclination would be to just increase the TCA that is already being used and bring it up to therapeutic levels for antidepressant and anxiolytic effects. The TCAs are very effective antidepressants but come with a wider array of side effects, which makes compliance a bigger issue with these...
How do you manage a patient with severe mental illness whose psychiatric symptoms worsen significantly during inpatient cancer treatment?
There are many issues to keep in mind, such as not all "mental illness" is necessarily a primary psychiatric disorder. Below are some common problems: For management of steroid-induced psychosis/mania, which typically has an onset within 3–4 days with risk >80 mg/day prednisolone equivalent. I would...
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...
How do you weigh the risks of antipsychotic induced metabolic side effects when treating behavioral symptoms of dementia in a patient with diabetes?
This is an excellent question and is a difficult clinical metabolic risk concern in a poorly characterized population. Most of what we know about antipsychotic-induced metabolic syndrome, such as weight gain, dyslipidemia, insulin resistance, and hyperglycemia, comes from younger patients with schiz...
Is there sufficient evidence yet to support the use of lithium supplementation or prescription in the management of neurodegenerative diseases?
No.I assume the question was written in response to a recent publication in Nature (Aron et al., PMID 40770094), highlighting recent research in mouse models where lithium deficiency in the brain led to accelerated amyloid pathology, which could be in part reversed by replacement.I want to remind th...
When do you suspect an autoimmune encephalitis in a child or adolescent with new-onset psychosis?
Given the rarity of true childhood schizophrenia, autoimmune encephalitis, and other medical etiologies should be considered in any patient presenting with new-onset psychosis prior to age 13. In adolescents, sudden onset of symptoms, absence of family history, lack of prodrome, and other atypical p...
How do you discuss sexual and gender identity-related anxiety with teens when family dynamics are rigid or culturally conservative?
First and foremost is safety. Never put children or teens in danger by hostile family or neighbors. In other words, don’t out them or encourage them to out themselves if they don’t feel safe doing so. You never know how people around them might react. That means be careful with your documentation, t...
Do you recommend GLP-1s for antispychotic induced weight gain?
When antipsychotic induced weight gain causes obesity (BMI>30), I recommend a trial of tirzepatide or semaglutide. I have observed the typical benefits in my patients, including decreases in lipids, lower HgbA1c, lower BPs, improved mobility, and loss of 10-20% of body weight over 6 months. Expense ...
How do you address sleep disturbance related to cessation of daily cannabis use?
First of all, I think challenges with sleep and daily cannabis use are underappreciated. We often hear that individuals use cannabis to help them relax and fall asleep. I'm going to highlight findings from a recent review by Kaul et al., PMID 33580483. Similar to what our patients report, acute or s...
How do you handle requests for disability or accommodations in clinical settings with limited administrative support or documentation time?
If you are working in private practice without ancillary support like case managers, I highly recommend having patients make appointments while you complete the forms for them. Clinically, if paperwork is being sprung on you out of nowhere, an evaluation is necessary anyways to determine if it's app...