Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Which cognitive screening tools do you use when evaluating older adults with suspected dementia?
In keeping with Alexander Luria's (paraphrased) maxim that knowing what a patient gets wrong on cognitive screening is incomplete until you know why/how they erred, I'd say the tool used is less important than interpreting it. So, I don't worry too much about MMSE vs MoCA vs SLUMS (as long as the MM...
How do you approach managing perioperative anxiety in Mohs patients?
Great question. Music, stress balls, having your team engage in conversations with the patient, and other distraction techniques are helpful. Some patients may need medications such as Halcion to help with anxiety but this should be given after the patient signs consent and has a verified driver aft...
How do you decide who to rechallenge clozapine after it was discontinued for a neutropenic episode?
The clozapine rechallenge of the patient previously treated with clozapine but having it discontinued due to clozapine induced neutropenia or absolute neutropenia now has a sizable evidence-based literature suggesting that it can be done safely and successfully. Selecting patients with previous disc...
How have you approached monitoring for severe side effects of ketamine treatments in the treatment of depression?
So... I'd say I'd never seen such severe side effects in my patients, and partially this is because ketamine infusions, done according to the expert guidelines (we use APA expert guidelines), are quite safe. We absolutely get a medical workup on every single patient, and we repeat the same workup on...
When do you refer a patient with difficult-to-treat depression for esketamine nasal spray versus IV ketamine treatment?
For treatment-resistant depression (TRD), intravenous ketamine is slightly more efficacious than intranasal esketamine (Spravato), probably due to more controlled bioavailability (all the substance administered is absorbed) and better personalization of doses. However, IV ketamine is usually not cov...
How do you approach managing intolerable vivid dreams as a side effect of SSRIs?
Given that the dreams are described as intolerable, I would transition to an agent more favorable in terms of sleep architecture, such as vilazodone (Viibryd).
How have you gone about implementing TMS in your practice or institution?
For me, the hardest issues with TMS are getting insurance to approve it and the time it takes from a patient’s perspective to see a benefit.When I first invested in the TMS machine, I calculated it could take up to 3 years to pay off the equipment cost. In actuality, I was able to recoup the initial...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
How do you counsel patients on cannabis use for PTSD?
In general, I recommend stopping cannabis. The large stratification study from the VA (sorry, only one cup of coffee and late night last night, so blanking on the authors or year) looking at patients who never used (19,000), chronically used before and during 3 months of treatment (2000), picked up ...