Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...
How do you manage acting-out behaviors in children in short-term crisis settings?
Managing behavior is a complex concept and difficult to address in a generic way. In general, it's helpful to conceptualize behaviors using the ABCs of a behavioral analysis. First, what is the antecedent to the behavior? This may take different forms depending on the environment. A general emergenc...
What policies do you take regarding legalized recreational marijuana or medical marijuana use in transplant patients?
The use of THC and CBD is becoming an increasingly important topic in solid organ transplantation. Recent survey data has demonstrated that daily cannabis use is higher than daily alcohol use in the U.S. (Caulkins, PMID 38775461).Certainly, the legalization of THC use in many states has led to consi...
When do you consider using phenobarbital over symptom-driven alcohol withdrawal protocols for patients at low-to-moderate risk of withdrawal complications?
While traditional frameworks often reference "low" or "moderate" risk for alcohol withdrawal complications, in clinical practice we find it more useful to focus on the treatment setting and validated predictors of severe withdrawal rather than subjective risk labels. Phenobarbital is increasingly us...
How do you decide whether to start MAT for opioid use disorder during hospitalization?
There are several considerations when approaching patients about MOUD. In general, every patient should be offered MOUD during their hospitalization because every admission represents an opportunity towards substance recovery. With that said, I don’t entangle substance use treatment with their medic...
What strategies have you found helpful to manage SSRI associated night sweats?
Reduced dose to the lowest effective dose. Gabapentin can be used off-label for hyperhidrosis and vasomotor symptoms of menopause. I had one patient on an SSRI for GAD and found the gabapentin helpful enough for anxiety that he tapered off the SSRI. If it is just night sweats, you can do a nightly ...
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...
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...