Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach the use and titration of Cobenfy in patients with treatment refractory schizophrenia not responding to clozapine?
It depends on what medications they are on. If they are on clozapine and you want to cross-titrate, then it will depend on the dose of clozapine and how fast you want to take it off, as we do not want cholinergic rebound. Let's say they are on clozapine 300 mg po qhs, then you can start Cobenfy at t...
When do you consider antipsychotic augmentation of antidepressants for PTSD?
Traditionally, antipsychotic augmentation of antidepressants was reserved for patients with high levels of paranoia or frank psychosis. The VA Cooperative Study of Risperidone also found that antipsychotic augmentation could be helpful for PTSD-related insomnia. The recent brexpiprazole study (Davis...
How do you counsel patients with mild to moderate depression interested in using St. John's Wort?
Although this is used in parts of Europe, there it is considered a pharmaceutical and has higher standards for dose and potency. Here, as it is a health food product, different batches may require different doses of the pill due to differences in potency. There is some data to suggest that the combi...
How do you approach the titration of Ambien (zolpidem) to treat catatonia?
I have no experience of using Ambien for catatonia, but have read an article from the NIH library, which shows a promising alternative when lorazepam does not work and ECT is not available readily. These are only case reports. Research is needed.
What is your threshold for writing disability letters for patients with personality disorders?
I don't believe it's appropriate to have a threshold. Patients with personality disorders are often stigmatized and assumed to be manipulative or malingering. The criteria for writing a disability letter should be "Is the patient's disorder such that they are unable to work?" Assessing their recent ...
For those who don't have access to addiction medicine, have you considered using naltrexone for the treatment of stimulant use disorder in your primary care clinic?
I often reference the ASAM stimulant use disorder guidelines available online, which offer several off-label medications for both cocaine use disorders and amphetamine use disorders, respectively, given other concomitant conditions. Of note, the only gold standard and approved option for treatment o...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
Is there a potential role for GLP-1 receptor agonists in the management of premenstrual dysphoric disorder?
This is an interesting question! I don't think we have enough information yet to answer, but I wouldn't be surprised if we find some benefit for PMDD, premenstrual exacerbation of symptoms, and PMS. This might be related to the anti-inflammatory effects of GLP-1 drugs, improved management of diabete...
What is your approach to evaluating Tardive Dyskinesia in nonverbal patients?
Nonverbal patients can still be affected by TD, so if there is a significant functional impact, treatment can still be offered. If a patient is completely unable to communicate, it is difficult to assess for side effects or symptomatic improvement, so the risk-to-benefit analysis would be largely un...
How do you approach treatment-resistant depression and anxiety related to menopause refractory to SSRI/SNRIs and hormone replacement therapy?
First, I try bupropion and have found that the dopaminergic medication is excellent for refractory depression, especially as one ages because dopamine gradually decreases 10% per decade (Berry et al., PMID 27807030). If bupropion doesn't help, then I have used pramipexole quite effectively over the ...