Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach stimulant prescribing for ADHD when a patient has previously reported palpitations with stimulants but has a normal EKG off medication?
One time EKG is not enough to rule out a cardiac problem. If an EKG is done at the time of palpitations, it can yield more information. One needs a Holter monitor for 3 days to one week to rule out arrhythmia. And an echocardiogram to rule out the structural and functional status of the heart. All o...
How do you approach stimulant prescribing for ADHD in a patient with auditory hallucinations, that can be command in nature (suicide), who will not take an antipsychotic medication?
Without knowing more history, I would never prescribe stimulants for such a patient. I respectfully disagree with Dr. Gill. Stimulants can cause and do exacerbate psychosis. And I’m not sure what Dr. Gill means when he says Wellbutrin is the culprit? A patient with Chronic Schizophrenia with Acute E...
How do you treat extrapyramidal symptoms secondary to anti-psychotic use in patients who have not benefited from cogentin or benadryl?
In general, when addressing motor symptoms from antipsychotics (or any dopamine-blocking agents including dopamine-blocking antiemetics), I find it useful to break things down more specifically than just EPS. This often will determine the agent that will be most beneficial. First Category: Hypokinet...
What medications do you prioritize or avoid in Parkinson’s Disease-related psychosis and behavioral disturbance?
From an evidence-based perspective, clozapine continues to have the most solid support for its efficacy in Parkinson's disease-related psychosis. Pimavanserin has FDA approval (albeit with some mixed data) specifically for this indication. Quetiapine and olanzapine are perhaps the most frequently us...
How do you approach the use of antipsychotics, such as Seroquel/Zyprexa, for insomnia in patients unresponsive to standard treatments?
I still avoid sedating antipsychotics, including quetiapine, unless there is a compelling comorbid indication. I prefer advancing to eszopiclone, higher dose pregabalin, and/or an orexin antagonist at the higher end of the dose range, given that the lower doses were not as dramatically effective ove...
Are the laws regarding prescribing C-2 medications different for mail order pharmacies?
This is an important question and very timely considering the increase in mail order pharmacies. As a practitioner, you can prescribe medications to patients within your state through legitimate mail-order pharmacies located in different states because these pharmacies are licensed to operate acros...
How do you adjust antipsychotic treatment during pregnancy?
Thank you for the question. In general, I try to make as few medication changes during pregnancy as possible, and try to ensure that patients are relatively stable from a psychiatric perspective for several months before conception. Obviously, this is not always feasible. If a patient needs introduc...
How do you treat TBI-associated aggression?
Propranolol has the best evidence, but you can also consider Depakote (since there is an increased risk of seizure as well) or an atypical antipsychotic. Fleminger et al., PMID 17054165 Williamson et al., PMID 31289093 Khalili et al., PMID 32002583
How do you decide between initiating antidepressants vs. hormone replacement therapy for post-menopausal depression?
I think the most logical answer to this is to treat what is deficient. The Women's Health Initiative Study and the following media reports on it were one of the most damaging OB/GYN and psychiatric mishaps in recent history, scaring half of women off of their HRT in a 6-month period. For some reason...
How do you decide between using immediate-release versus long-acting lithium?
In general, long-acting (i.e., controlled release) lithium is thought to cause less nausea and other common side effects (like tremors) than IR formulations but has also been associated with higher rates of diarrhea due to differences in absorption. Another consideration may be the dose you are try...