Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you weigh risks/benefits when referring child and adolescent patients for ECT?
I want to begin with a disclosure: I do not personally treat children with ECT in my practice. However, in a prior academic setting where ECT was performed for adults, I was occasionally asked to evaluate adolescents being considered for treatment by the adult ECT service. When thinking about referr...
How do you respond to early refill requests for stimulants in stable patients who report lost or stolen medication?
I do not refill stimulants when they are reported lost or stolen. When starting a treatment course of stimulants with a patient, I review a brief list of instructions and expectations. For stimulants, this includes that it is their responsibility to store and protect their medication from theft or l...
How do you manage ARFID in children encountered in your practice?
ARFID is a fairly new disorder, having been added to the DSM in 2013. Treatment somewhat depends on the type of ARFID with which the patient presents, although there are shared treatment elements regardless of type. Variants include Avoidant type, which usually revolves around sensory issues related...
What role do you think AI-based clinical decision-making aids should play in psychiatric practice today?
Not yet. AI is still in its infancy and may be prone to "hallucinating" answers, as indicated by the legal cases where AI simply manufactured case precedents that don't exist. This is a risk that is probably not necessary in psychiatric diagnosis and treatment at this point in history. Although usin...
When have you found the Nidra TOMAC device to be helpful for refractory restless leg syndrome?
I have one patient who found it helpful with breakthrough symptoms in refractory RLS, but was unable to get enough coverage to continue using it.
Other than firearms, what dangerous items do you recommend removing or securing as a part of safety planning?
Medications, including over-the-counter (OTC) Sharps, including knives in the kitchen (this will be tough for the family - I have had them remove from drawers and keep one secure for use until the acuity resolves) Cleaners (all bathroom/kitchen cleaners) Alcohol
What opportunities do you see for combining xanomeline-tropsium (Cobenfy) with other anti-psychotic agents?
The opportunities of combining Cobenfy with any of our other antipsychotic treatments, in my opinion, are unlimited. This is one of the most important aspects of its drug use that has NOT been systematically tested. One might think first of combining Cobenfy with a widely used drug, like risperidone...
When do you consider writing an Emotional Support Animal (ESA) letter for patients with psychiatric illness?
After much soul searching, I decided that I cannot write these letters. The hard part for me is that I'm an animal lover and a pet owner, and I really do appreciate the happiness and comfort that a good animal companion can provide. But the letters are complicated, because for FHA benefits, you are ...
When do you consider pharmacogenetic testing to assist in the selection of antipsychotic medications?
I don't usually consider it, as the evidence of clinical use isn't warranted unless the patient is on heroic dosing or has side effects to every medication. I usually will get plasma levels, and you can get plasma levels for pretty much any antipsychotic - it's a cheaper GeneSight. For example, if I...
How do you counsel patients/give data on long-term use of second generation antipsychotics and risk of involuntary movement disorders?
I never try to use SGA as an adjunct for MDD augmentation - if anything, it might be Caplyta (recently FDA approved and lower side effect profile). I have seen tardive dyskinesia from 1 year of Abilify with Zoloft from a PCP. So I am very hesitant to start an antipsychotic as an adjunct. But at the ...