Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach mood stabilizer selection for older adults with bipolar II disorder?
Depending upon age, medical illnesses, other medications the patient is on, and the symptoms, the appropriate medication will be decided. If the patient is hypomanic, a mood stabilizer will help. Also, if the patient is on an antidepressant, reducing the dose or even stopping it can be a choice. If ...
How would you manage a healthcare provider with major depressive disorder when their condition is suspected to impact their job performance?
This is a complicated issue that makes us all a little uncomfortable. There are several issues one must consider. First, from the treatment side, the provider should be treated like all other patients. You should be mindful of the side effect/benefit profile of the treatments and avoid or use them t...
How do you approach evaluating sudden mental status changes in telepsychiatry patients, particularly older adults, when medical causes such as infection or metabolic disturbance may be contributing factors?
I am dealing with a few now, but during the pandemic, I had more. Sudden changes in mental status definitely need medical clearance. Helpful questions try to elicit findings about urinary changes, fever, and weakness, especially if I'm certain parts of the body show other symptoms like nausea, vomit...
How do you manage anxiety for patients who are experiencing a myasthenic crisis?
For a long time, we have been taught that we should avoid benzodiazepines in this setting (also applies to patients with ALS, myositis, etc.) because of their suppressive effect on the CNS respiratory drive and the risk of exacerbating hypercarbic respiratory failure. Based on recent conversations w...
What strategies do you use for patients on medications for ADHD who experience afternoon rebound/withdrawal?
There are several strategies to try. The first thing I do to address withdrawal dysphoria is usually a high-protein snack about 30 minutes before the symptoms are typically noted. In most of my pediatric patients, this is a game-changer. If that's not helpful, you can consider using a short-acting s...
How do you define treatment-resistant depression in your practice?
Well, technically, treatment-resistant depression is defined as no meaningful response after at least two trials of antidepressants at therapeutic doses and durations (≥8 weeks). The first step is to rule out inadequate dosing (try to reach the max dose), poor adherence, and medical comorbidities th...
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
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...