Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
In a woman with bipolar disorder with a menstrual component would lamotrigine itself worsen the condition given that it interacts with prescribed estrogen?
Very unlikely. Estrogen can cause a lowering of the Lamictal serum levels and not vice versa. So, if a patient on Lamictal is put on an estrogen product, there may be a need to increase the dose of Lamictal.
What parameters do you follow to avoid rebound effects when using clonidine only for nightly or daily as-needed indications?
I use a fair amount of clonidine in my practice, and I haven't found any rebound blood pressure effects for people who take clonidine nightly or for PRN use. In fact, I've stopped routine practice of checking blood pressure for those who are not taking a standing daily dose. I worry about rebound mo...
How do you approach managing clozapine in patients who are critically ill?
With COVID-19 disproportionately affecting those with mental illness we found an increasing number of medical admissions for those on clozapine. There are multiple domains of concern for those on clozapine who are medically ill. Clozapine levels have been shown to potentially double during periods o...
When do you start pharmacotherapy for PTSD in children?
The only medications to be used are to address sleep disturbance and nightmares. Poor sleep has been shown to increase PTSS. So prazosin and, on occasion, clonidine should be used. And they should be used as early as possible. SSRIs are generally not that effective and should only be considered if t...
What is the role of inpatient psychiatric or psychological evaluation in patients who have had acute function change as an inpatient?
This is an important question. An acute change in function is a frequent reason for hospital admission and must be considered as a feature of some underlying medical, neurological, or psychiatric condition. It is important to know what functions have changed, including basic and instrumental activit...
How do you approach treatment-refractory schizophrenia which has not responded to multiple antipsychotic trials including clozapine?
I would also add that there are now case reports and case series of the ketogenic diet having significant benefits for the treatment of refractory schizophrenia, including some cases of those who had not benefitted from clozapine. The mechanisms of action by which a ketogenic diet improves brain hea...
What varying approaches do you take in suicide risk assessments?
I agree with the following from Dr. @Dr. First Last: "Ultimately, no scale or method is going to be perfect. We are unfortunately bad at predicting which individuals with suicidal ideation progress to an attempt. The most we can do is gather as much information as possible about how someone is feeli...
How do you manage nausea side effects in patients on cariprazine?
Have them try taking it every other day. This can offset side effects, given the long half-life.
How do you approach the use of benzodiazepines in patients with chronic medical illnesses that may be susceptible to respiratory compromise (e.g., CHF, COPD, ILD)?
It’s a very good question and answers may vary among different specialty providers. Yes, a slow or gradual weaning of the benzodiazepines would be advisable. When they reach lower doses the taper should be even slower over weeks or longer. There is a risk for not weaning them off benzodiazepines inc...
What considerations do you take regarding using valproic acid in men who are hoping to conceive with a partner?
This recommendation was based on an analysis of one retrospective study, with data being re-analyzed, in addition to case reports and animal studies. It seems to me that it's too soon to be making rash decisions about treatment, but informing patients of the possibility and uncertainty seems reasona...