Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
What strategies have you found effective in improving acceptance of long-acting injectable antipsychotics in patients with serious mental illness who are ambivalent about treatment?
Good question. I think it's important to understand the patient's perspective, because everyone can have a unique fear regarding LAIs. It could be that they have a fear of needles, are concerned about a lack of autonomy, or are worried about the mechanism of action and potential adverse events. You ...
What is your approach to using newer atypical antipsychotics in the treatment of schizophrenia?
Latuda - great for mood stabilization and bipolar depression. A lot of people like it for borderline personality disorder, but it’s not FDA-approved for that. In my experience, not that great for psychosis or mania, but it also doesn’t really cause weight gain or QTc prolongation. Out of all the se...
How have you incorporated prescription digital therapeutic treatments for chronic insomnia, such as SleepioRx or Somryst, into your practice?
I have not yet prescribed any of the digital therapeutic treatments, but there are key differences. The US Department of Veteran Affairs developed CBT-i Coach based on the therapy manual CBT for Insomnia in Veterans, and the app is free to use. CBT-i Coach is intended to augment face-to-face care wi...
How do you counsel breastfeeding parents with postpartum depression when sleep deprivation appears to be worsening mood symptoms?
My position is that breastfeeding is a sometimes difficult practical issue, not a medical or moral imperative. I try to normalize the difficulties of breastfeeding, based on my own experience and that of my daughters and sisters, countering the exploitation of anxiety around this issue with problem-...
When have you found hypnosis helpful for parasomnia?
Usually, when treating NREM parasomnias such as sleep terrors and sleepwalking, the patient has to practice the techniques every night in addition to removing identified triggers.
How do you counsel patients who want to understand why sublingual cyclobenzaprine works to relieve their fibromyalgia pain and other related symptoms?
I like to set the stage with patients and make sure they clearly understand the link between sleep disruption and pain sensitivity, particularly in the context of central pain and fibromyalgia. One of my rheumatology attendings during fellowship used to explain this using classic sleep research from...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
What clinical factors guide your decision about if and when to restart antipsychotic medications in patients with primary psychotic disorders recovering from catatonia after stabilization with benzodiazepines or ECT?
The American Psychiatric Association's catatonia workgroup recently published an excellent Resource Document for Catatonia.In this document, they discuss some relevant points on pages 25 - 27: There is a longstanding history of using antipsychotics in catatonia, with available reports on the use of ...
What is your approach to using clonidine for anxiety?
It definitely helps in patients with autism with anxiety, 0.1 mg po bid but not my first line because of the blood pressure drop or rebound. I don’t use it as a first line for anxiety, as I haven’t seen any improvement if it’s just used for anxiety. Strattera has some evidence for anxiety in autism,...