Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage cannabinoids (ex: medicinal, recreational) in dermatology?
I use dronabinol 2.5-10 mg qd-tid for recalcitrant pruritus (typically neuropathic or CPUO as an adjunct treatment). Very cheap using GoodRx if not covered by insurance. It’s a scheduled drug, so it requires DEA, but you don’t need a “medical marijuana license,” and it’s very well tolerated outside ...
When do you consider adding an antipsychotic for SSRI-refractory OCD, and which agent do you typically choose first?
There are so many factors that play into my decision-making; it truly is a case-by-case basis. In my opinion, the most common mistake is not adequately titrating the dose of the SSRI. You also need to make sure they are getting high-quality CBT/ERP at least 1x/week, ideally 2x/week for the first mon...
What is your approach to managing sexually inappropriate behaviors in hospitalized patients with psychotic symptoms?
Sexually inappropriate behaviors, commonly abbreviated as ISB in the behavioral and sex offender treatment communities are very often problematic, especially when combined with psychosis. ISB can vary from relatively mild, such as accidental self-exposure by a confused patient, to the very severe, s...
How do you approach continuation of benzodiazepines in elderly patients with anxiety who have had poor response to other medications?
This is a risk/benefit analysis question, and will be unique for each patient. The biggest danger is making an internal rule that ignores the patient's needs. Many variables come into play: if the person has been on them for years or decades, then it probably causes more harm to discontinue, as they...
What is the role of cognitive training exercises in older patients with short-term memory problems and/or are diagnosed with mild cognitive impairment?
You are correct. The evidence so far is level C - as far as I know. No robust RCTs. Exercise gets a Level B recommendation. You may maximize benefit by offering more supervision (supervised computerized cognitive training), combining with resistance training, and/or increasing frequency. Most effect...
How do you approach diagnosing suspected early tardive dyskinesia with minimal positive findings on AIMS examination?
Before adding any medications, I generally try to remove any offending medications, like antipsychotics, or meds like stimulants that can lead to tardive tics. One can see TD with SSRI medications, but it is rare. If I suspect TD despite not having a positive AIMS test, I will sometimes have patient...
How do you manage problematic disinhibited behaviors in patients with neurocognitive disorders?
This requires a problem-centered approach. I suggest the following thought process. Analyse the root cause: Is it disinhibition? Unmet needs? Under/Overstimulating environment? Medication side effect? For disinhibition (frontal lobe dysfunction): I have had success with gabapentin and low-dose Depa...
What medications do you recommend for a patient with ADHD and anxiety who becomes more anxious on a stimulant?
Consider non-stimulant ADHD medications such as atomoxetine and viloxazine. Although these are not as effective for nearly as many patients as the stimulants, they are a reasonable alternative and generally well tolerated. Despite the potential for bupropion to also cause a patient to feel more anx...
What is your approach to titration of sublingual cyclobenzaprine in your patients with fibromyalgia?
Follow the FDA instructions: start at 2.8 mg sublingually at bedtime for 14 days, if tolerating, then increase to 5.6 mg nightly starting day 15 onwards. Ensure the mouth is not too dry as saliva is needed for it to fully dissolve, which could take 2-3 mins. This may be a concern in patients with SI...
How do you approach patient requests for long-term disability for major depressive disorder?
There is the medical side to this question and the documentation. Incidentally, oftentimes if there is a forensic issue to the disability, it is very difficult for the disability to be resolved until the forensic piece has been resolved. Have you and the patient determined that disability is clearly...