Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What precautions should be taken when discharging a patient from the medical setting on new medication assisted therapy for alcohol use disorder?
Great question. This article absolutely adds to the argument for using medications for alcohol use disorder. The precautions would mostly explain side effects, just as you would for any new medication. A few specific considerations depend on the medication (I'll restrict this to four more common cho...
How do you engage and approach a patient presenting with psychotic symptoms who has demonstrated a pattern of malingering and also has polysubstance use disorder?
This is a nice general summary of some basics, non-judgemental, supportive approach, quiet/low stimulation environment: Mental Health First Aid Guidelines. With regards to malingering and how to approach it, try to determine the real want/need (housing or food insecurity?) and if it is something tha...
What recommendations do you have regarding the use of dronabinol to prevent cannabis withdrawal in an inpatient medical or psychiatric setting?
I routinely use dronabinol in patients who are heavy/daily cannabis users and are having a hard time as inpatients with any degree of withdrawal and cravings. It can be a good anxiolytic as well as antiemetic and orexigenic in this situation. Depending on their preferences, it can be scheduled with ...
How do you manage patients with alcohol use disorder who express interest in moderation rather than full abstinence?
In the past, I would try to engage these patients in complete recovery—AA, etc. Today, having read the literature on harm reduction and perhaps being more experienced and tolerant with age, I engage the patient in healthcare activities like exercise, sleep, and diet, and discuss recovery from alcoho...
How do you approach weaning patients off of buprenorphine?
I have found using injectable extended release buprenorphine (XR-BUP) as a good way to help patients taper off SL buprenorphine in a means much more tolerable than trying to taper SL buprenorphine. We published a case series on this approach (Ritvo et al., PMID 32925232) and subsequently another cas...
Have you incorporated National Acupuncture Detoxification Association (NADA) ear acupuncture into the treatment of substance use disorders?
No, not necessarily. Perhaps on a case-by-case basis, and with patient request, this option is considered. Don’t have evidence-based data to support its use.
When do you use SNRIs or norepinephrine reuptake inhibitors (e.g., atomoxetine) for the treatment of ADHD?
Diversion of stimulants is a concern. However, patients with ADHD symptoms who have a robust response to stimulants are motivated to continue treatment and to ensure compliance. I have not found SNRIs, SSRIs, or bupropion effective for ADHD but agree that they may be indicated for comorbid anxiety a...
How do you decide which commercially available pharmacogenetic test to use for your patients?
I try to avoid the use of these types of tests because my experience is that they overpromise what is possible for them to deliver to the patient/consumer. It may be the case that if you have decided an SSRI would be the best treatment, then perhaps these tests can tell you which SSRI might be metab...
Have you observed adverse mental health side effects in patients who start montelukast?
A female patient with anxiety but no history of depression or suicidal tendencies developed suicidal ideation with intrusive thoughts while taking montelukast. These were resolved within days of stopping the medication. I also treated a child brought in by his parents for extreme and sometimes viole...
What is your approach to treating panic attacks/disorder with psychotic features?
Stelazine has FDA approval for non psychotic anxiety - I've used it to good yet limited success (n=2). 2 mg po bid prn