Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
In what clinical situation would you consider using benzodiazepines in patients with dementia?
When a dementia patient is in the moderately severe or severe stages of the disease and has palliative goals of care, they would be eligible for palliative care FAST 6 or hospice FAST 7. Caregivers are no longer trying to maximize independence. The patient has 24/7 supervision. The caregiver is at r...
Given some of the theoretical relationship between glutamate and OCD, do you ever consider the use of NMDA (or AMPA) antagonists for the treatment of refractory OCD?
We recently published a systematic review and meta-analysis on glutamate-modulating agents in the treatment of OCD as augmenting agents to SSRIs or as monotherapy. Overall, we found that glutamatergic medications led to significant improvement (statistically and clinically) in OCD symptoms. We also ...
What strategies have you found effective in reducing intake no-show rates among patients with severe and persistent mental illness?
Reducing no-shows for community-based intakes depends on how people are initially engaged. Relationship building is always an important factor. Maintaining contact with the referral source and providing several prompts for the appointment to the client begins the process. Providing incentives to att...
What considerations do you take in starting stimulant medications for the management of adult ADHD?
Adult stimulant prescriptions for ADHD and The Journal of the American College of Cardiology in particular have published several articles in the last few years investigating the cardiovascular risk of long-term use of these medications. There have been three already in 2024 and data remains mixed.I...
How do you monitor patients who are symptomatically well-managed on clozapine with supratherapeutic drug levels?
I generally adhered to the published NIH guidelines (Correll et al., PMID 35759211). It also looks like we will be changing everything pretty soon as these recommendations will change.I still plan to do regular neutrophil and WBC counts, definitely not as frequently as previously recommended, but I ...
Do you believe that buspirone is ineffective in patients who are previously treated with benzodiazepines?
I've found buspirone helpful for patients who don't want to taper their benzo unless they have another medication on board. I wait until the buspirone is at a stable dose (typically at least 15 mg BID) before tapering the benzo. I specifically avoid cross-tapering/titration as I worry they will asso...
When do you consider pharmacogenetic testing to assist in the selection of antipsychotic medications?
I don't usually consider it, as the evidence of clinical use isn't warranted unless the patient is on heroic dosing or has side effects to every medication. I usually will get plasma levels, and you can get plasma levels for pretty much any antipsychotic - it's a cheaper GeneSight. For example, if I...
Do you routinely prescribe an anticholinergic agent for EPS prophylaxis when starting or continuing antipsychotics or do you prefer to use it only as needed (PRN) if/when symptoms develop?
In the setting of starting long-term treatment with antipsychotics, anticholinergics should not be started automatically for prophylaxis of EPS. Anticholinergics have numerous significant side effects and often are continued indefinitely without ever clarifying if patients actually have EPS.Antichol...
What is your approach to using stimulants in treating children with both ADHD and autism?
I think the most important thing to understand is that stimulants can be helpful but perhaps less frequently helpful and often with more side effects than in children with ADHD only. So low expectations with awareness of and preparation for the potential of significant worsening is key. A few other ...
What strategies have you used to facilitate insurance approval of off-label psychiatric medications for children and adolescents?
Off-label (i.e., non-FDA-approved) medications are frequently used to treat psychiatric disorders in children and adolescents. One reason for this is that even FDA-approved medications that have been shown to be effective for child and adolescent psychiatric issues don't always work with every patie...