Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you use extended-release buprenorphine instead of daily formulations?
Extended-release buprenorphine (e.g., Sublocade, Brixadi) can be a good option for patients who have trouble staying stable on daily sublingual doses, especially those with adherence challenges, ongoing exposure to high-risk opioids such as fentanyl, or concerns about safety and diversion. Weimer et...
How do you evaluate and manage patients who report vivid, distressing dreams or “epic dreaming” that disrupt sleep quality?
Nicotine or nicotine replacement being used? (Very common cause) Varenicline (Chantix) for smoking cessation being used? (Known effect) Melatonin being used? (Possible, more likely with high/excessive doses) Recent reduction or cessation of an antidepressant resulting in REM rebound? (Known to cause...
What is your approach to recommending bright light therapy devices to patients with (seasonal) depressive disorders?
Bright light therapy has a strikingly positive evidence base for seasonal affective disorder, major depressive disorder, and even bipolar depression. I recommend shopping for a lamp with 10,000 lux, a large format, diffusion screen (possibly fewer headaches), and one that is on a stand so that it sh...
What is your approach when the child refuses to separate from parents during psychiatric evaluation?
Children sometimes refuse to separate from parents during a psychiatric evaluation. The simple answer to how I respond when this occurs is that I complete the interview with the parent(s) in the room. For preschoolers and many school-age children, a refusal to separate is not necessarily something t...
Do you taper memantine after completion of 24 weeks of therapy?
Tapering is recommended when discontinuing some medications used in the management of dementia such as cholinesterase inhibitors. There are anecdotal cases of “discontinuation syndrome” after abrupt cessation of memantine in patients with dementia. However, this alone does not prove that a slow tape...
What is the best way to support a pediatric oncology survivor with fears about 2nd neoplasm or relapse?
Concerns regarding recurrence of the primary malignancy or the development of a second malignant neoplasm are common among pediatric cancer survivors and may be a significant source of ongoing anxiety. It is therefore important to routinely assess for these concerns, as well as to screen for anxiety...
How do you approach ADHD treatment in patients with psychotic disorders who are now psychiatrically stable?
In my practice, I find that we often move too quickly to label ADHD in patients who are already struggling with a psychotic disorder. We seem to have forgotten the value of hierarchical diagnosis. In my view, psychotic disorders are global in nature; they impair the entire "stream" of a patient’s ex...
How should psychotherapy techniques for patients with autism spectrum disorder be adjusted, if at all?
The answer depends, at least in part, on the level of ASD with which the patient presents. Psychotherapy can be very useful for patients with Level 1 ASD, but some individuals with Level 1 ASD are more capable of benefiting from therapy than others. In general, using a more structured approach, allo...
What doses of lithium have you found effective in reducing suicidal ideation?
For depression augmentation in patients who have non-bipolar states, I generally use 150-450 mg (low-dose lithium). The blood levels usually range below therapeutic for bipolar, but the low-dose lithium can help reduce SI without too many side effects. I still watch for issues of thyroid and kidney ...
How do you view the risk of tardive dysinesia and other side effects in your female patients with treatment-resistant depression who are stable on an atypical antipsychotic?
Superb question, and it also applies to bipolar disorder, which is even more challenging in this patient population. I like Dr. @Dr. First Last's answer, always a risk/benefit analysis. Probably what you are already doing is my guess, since you are asking this question. Make sure you are doing consi...