Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you treat withdrawal symptoms from kratom addiction?
Consider buprenorphine for kratom addiction and withdrawal. I have seen patients developing kratom addiction in the context of trying to get off full agonist opioids. A variety of PRNs for symptom management (e.g., trazodone for sleep) can be helpful. I would also encourage counseling, overdose educ...
Would you consider changing management for a patient with bipolar disorder stable on an antipsychotic who is on anticoagulation after a recent PE or VTE?
Not necessarily, no. INR is followed regarding anticoagulation with warfarin, and can be adjusted accordingly to optimize INR.
What is your preferred first-line agent to treat anxiety in patients with Parkinson's disease?
Any standard SSRI/SNRI can be tried. I like to try the SNRIs duloxetine or venlafaxine. If comorbid insomnia is a problem, mirtazapine may be a good choice. Think about talk therapy too. It is important to make sure episodic anxiety is not a non-motor symptom fluctuation related to levodopa or oth...
Do you modify dosing or use of bupropion to mitigate seizure risk in patients without eating disorder who are restricting calories to lose weight?
No. The risk of seizures with bupropion is 0.1% with daily doses below 300 mg and 0.4% with doses up to 450 mg daily. The increased risk of seizures in eating disorders is due to higher risk of severe electrolyte disturbances that result from disordered eating, induced vomiting, and laxative abuse. ...
How do you discuss the mechanism and potential benefits of meditation with your patients?
What is the benefit of meditation practice? Thoughts and emotions are molecules interacting in a chemical solution called the human body. We cannot change a molecule that is already here, but when we change the chemical solution in which molecules of thought and emotion are arising, interacting, and...
How do you manage therapy cases where CBT techniques seem to increase distress or exacerbate underlying rigidity?
This is a very good question, but the answer depends, among other things, on the specific CBT techniques that are being utilized, which are contributing to the increased distress. A usual culprit is Exposure, often used for addressing phobias as well as traumatic past events. Most patients who seek ...
Is there evidence to suggest there is a withdrawal syndrome from muscle relaxants such as tizanidine?
The answer is yes, there is evidence in published literature supporting withdrawal manifestations from sudden discontinuation of alpha-2 agonists including tizanidine (references below), primarily due to catecholamine surge causing a sympathetic overdrive, affecting the patient's physiological state...
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...
What is your approach to helping parents manage sleep disturbances in patients with autism spectrum disorder?
At our center, we start with sleep hygiene education, using tools such as the Autism Speaks sleep toolkit which has a printable PDF that is free for parental and clinical use. We also try to do therapy on sleep hygiene and our therapists will often try to find out what factors may exist in the home ...
How do you approach switching from methadone to buprenorphine/naloxone for patients who want to change medication management for opioid use disorder?
All of the above opinions are valid. I can guarantee, my dear colleagues, that if three hours are spent in one room, we could easily come to 5 different solutions and would be able to justify them. What is important is the reason for the switch, the comfort of the person who is switching, and makin...