Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Given the mixed evidence for N-acetylcysteine in adolescent cannabis use disorder, how do you approach discussing this with families?
A thoughtful addition to the discussion on NAC in adolescents with cannabis use disorder is to emphasize how and when it is used. In many young patients, cannabis use is not simply recreational or oppositional, but a compulsive attempt to manage obsessional anxiety. When this pattern is recognized—p...
What strategies do you find helpful to stop zolpidem in patients who have been taking the medicine for months or years?
Zolpidem has significant withdrawal, and if not careful, the patient will perceive it as a need for zolpidem for sleep. Technically, it is not working after about 6-8 months due to the accommodation of receptors. Please use lemborexant hintly for 1 week, reduce to 2.5 mg zolpidem for 1 month, and th...
How will your approach to screening and diagnosis of early dementia change given newly available therapies for early Alzheimer's disease?
As it stands, it is not recommended to screen asymptomatic patients for the proteins seen in Alzheimer’s disease outside of clinical trials (i.e., AHEAD 3-45). However, with the emergence of new treatment options in the clinic, I foresee an influx of patients with cognitive symptoms who need a preci...
Where in your treatment approach to fibromyalgia will you recommend sublingual cyclobenzaprine?
The choice of medication for any given patient is based on a lot of factors and, realistically, is often highly dependent on affordability and insurance coverage across different pharmacy plans. Despite other FDA-approved options, oral cyclobenzaprine is usually the medication I reach for first with...
When do you consider low-dose buprenorphine for the management of treatment resistant depression?
At doses of 0.25-2 mg, buprenorphine has potent kappa opioid receptor antagonism, and this conveys anxiolytic and antidepressant activities. It can be used in an augmentation mode with other antidepressants. See (Karp et al., PMID 25191915; Fava et al., PMID 26869247; Thase et al., PMID 31254971; Fa...
What workup do you consider necessary for “medical clearance” when patients present to the emergency department with altered mental status and possible psychiatric illness?
In the emergency room, whenever there is a question of altered mental status, we request UA+UTOX, CBC, CMP incl. LFTs, thyroid panel, B12, folate, b-HCG if applicable, and any related plasma medication levels +EKG. Based on a patient's substance use history or medical history, we might order additio...
How do you differentiate between HIV associated neurocognitive disease (HAND) and other causes of neurocognitive impairment?
This is a great question. In the era of test and treat, where many people with HIV have never had significant immunocompromise, cognitive impairment due to HIV itself is now relatively rare. On the other hand, people with HIV experience conditions of aging about 10 years earlier than people without ...
When do you write notes excusing children from certain school activities (ex. gym) due to anxiety disorder?
As a CAP who also works in schools, I usually try to coordinate with the school and therapist to best meet the patient's needs. Ideally, the child would be addressing their fears in therapy and would create a hierarchy of fears that they are working on. I would collaborate with the therapist, who is...
In children with unknown family cardiac history, do you require a routine EKG prior to starting a stimulant?
The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) have stated that ADHD medications have not been shown to cause heart conditions or sudden cardiac death, although stimulant medications do increase heart rate and blood pressure. By increasing sympathetic nervous syste...
What are the most effective strategies for managing weight gain associated with antipsychotic medications?
In my experience, the following things have worked. Reassurance that it is a medication side-effect. Consider switching the anti-psychotic (or at least try and decrease the dose of the antipsychotic). Aripiprazole, Caplyta (Lumateperone), and Vraylar (Cariprazine) have shown benefits vis a vis weig...