Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach the titration of Ambien (zolpidem) to treat catatonia?
I have no experience of using Ambien for catatonia, but have read an article from the NIH library, which shows a promising alternative when lorazepam does not work and ECT is not available readily. These are only case reports. Research is needed.
What is your threshold for writing disability letters for patients with personality disorders?
I don't believe it's appropriate to have a threshold. Patients with personality disorders are often stigmatized and assumed to be manipulative or malingering. The criteria for writing a disability letter should be "Is the patient's disorder such that they are unable to work?" Assessing their recent ...
For those who don't have access to addiction medicine, have you considered using naltrexone for the treatment of stimulant use disorder in your primary care clinic?
I am an addiction medicine clinician, and this is my general approach for treatment of stimulant use disorder (which is almost entirely methamphetamine use in my location of Portland, Oregon). Most of my patients have co-use of opioids, so they are typically unable to get onto naltrexone, and I reco...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
Is there a potential role for GLP-1 receptor agonists in the management of premenstrual dysphoric disorder?
This is an interesting question! I don't think we have enough information yet to answer, but I wouldn't be surprised if we find some benefit for PMDD, premenstrual exacerbation of symptoms, and PMS. This might be related to the anti-inflammatory effects of GLP-1 drugs, improved management of diabete...
What is your approach to evaluating Tardive Dyskinesia in nonverbal patients?
Nonverbal patients can still be affected by TD, so if there is a significant functional impact, treatment can still be offered. If a patient is completely unable to communicate, it is difficult to assess for side effects or symptomatic improvement, so the risk-to-benefit analysis would be largely un...
How do you approach treatment-resistant depression and anxiety related to menopause refractory to SSRI/SNRIs and hormone replacement therapy?
First, I try bupropion and have found that the dopaminergic medication is excellent for refractory depression, especially as one ages because dopamine gradually decreases 10% per decade (Berry et al., PMID 27807030). If bupropion doesn't help, then I have used pramipexole quite effectively over the ...
What has been your experience with alternative injection sites to the abdomen for improving pain/tolerability with buprenorphine extended release?
I agree with Dr. @Dr. First Last's comments about 1) rotating injection sites on the abdomen, 2) considering alternate sites per the new package insert, and 3) pretreating with lidocaine. In addition, I would recommend considering Brixadi, which has a smaller gauge needle (23G as opposed to a thicke...
How do you counsel patients when they ask whether the SSRI or SNRI antidepressant you have recommended will result in weight gain?
This recent study on antidepressant-associated weight gain has generated a lot of interest and press, and can be a helpful starting point: Petimar et al., PMID 38950403.As with all studies, it has its limitations, but highlights that many people will experience minimal-modest weight change on antide...
What treatments have you found to be most effective in patients with a schizo-obsessive disorder?
This is a good question, as this happens in about 30% of our patients who have this. It depends on the severity of the psychosis versus OCD. Sometimes it’s hard to tease out are we're dealing with psychosis or the OCD is so severe it comes across as psychosis. That’s the first step. Then, as I said ...