Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to duration, dosing, and continuation of lithium monotherapy in patients with a single lifetime manic episode stabilized on lithium?
Sometimes lithium is the only thing that works for patients with bipolar disorder, and in those cases, we also need to look at the calcium level because long-term use can also cause hyperparathyroidism. This is why we should look at labs every 3-6 months to monitor. If lithium is the only thing that...
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 do you counsel patients who are hesitant to try behavioral therapies for insomnia instead of starting a sleep medication?
I try to be very understanding of the desire to have an easier solution to sleep difficulties, which are so common. It is challenging that our gold standard and best strategies to help people sleep better require a lot of effort on the patient's part. Starting with that validation can be very helpfu...
How do you manage patients who send hostile or overly frequent messages through online patient portals in outpatient psychiatry?
This is a complicated yet important topic that should consider boundaries, diagnosis, threat assessment, and termination. Starting with boundaries, I think it is important for the clinician to establish the boundaries that they are comfortable with and share that information with the patient, all wh...
How do you counsel patients interested in neuromodulation (tDCS, rTMS) for ADHD?
I have not used rTMS for ADHD but have used it for adolescent depression. It is advised to spend a full appointment to go over the evidence, the strength of evidence, possibilities of failure, etc. I generally let parents and patients come back to me to ask for the procedure. In my opinion, for any ...
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...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
For children under the age of 7 with ADHD who continue to have significant impairment with behavioral interventions, how do you decide between starting with a stimulant vs starting with an alpha agonist?
If the ADHD symptoms are still impairing despite being treated with behavioral interventions, pharmacotherapy is indicated. First-line pharmacotherapy for ADHD, even in elementary school-age or younger, is stimulants. I would treat them with stimulants unless there is a contraindication or a reason ...
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-...
What is your approach to augmenting treatment for depressive disorders in those continuing to take a tricyclic antidepressant at baseline due to historical effectiveness?
Depends on the risk of suicidality. If there is any history or any hint of a possibility of it, I do not continue with a TCA. I would augment with a dopamine agonist. I only use TCA to help with multiple comorbidities, such as migraines, insomnia, neuropathic pain, along with depression - knowing I ...