Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach firearm safety counseling for outpatients with elevated suicide risk who do not meet the criteria for involuntary psychiatric hospitalization?
I have found the framework outlined by the BulletPoints Project (created by the California Firearm Violence Research Center at UC Davis) to be very helpful. I start by asking about the patient’s goals for owning firearms. I think it is important to recognize that guns often form an important part o...
When do you check vitamin D levels in patients with depressive symptoms?
I routinely check 25-OH D in all my patients. Given that half the population is deficient and that we now know the role of vitamin D not only for bones but in mood, cognition, and immunity. We need to be aware of deficiencies and replete if low. Moreover, ideal levels are 60-80, not just over 29 as ...
What has your experience been with using SSRIs to treat negative symptoms of schizophrenia?
Thirty years ago, I tried various SSRIs for negative symptoms, with no improvement according to the patient and caregivers.
How have you incorporated Eye Movement Desensitization and Reprocessing (EMDR) into your outpatient psychiatric practice?
Training is formal and takes one week, and the training I had was truly excellent and experiential. The EMDRIA website has a list of trainers and trainings. I have found EMDR to be a powerful modality that rapidly clears the negative emotions related to past traumatic or unpleasant events. I use it ...
What is your approach to using newer atypical antipsychotics in the treatment of schizophrenia?
Latuda - great for mood stabilization and bipolar depression. A lot of people like it for borderline personality disorder, but it’s not FDA-approved for that. In my experience, not that great for psychosis or mania, but it also doesn’t really cause weight gain or QTc prolongation. Out of all the se...
What is your approach to using prazosin to treat day-time symptoms in PTSD?
I will only use prazosin during the day if the patient is using it for sleep disturbance/nightmares. If they are not using prazosin, then I prefer guanfacine during the day. If using prazosin, I start at 0.5 mg in the morning and then BID. I will titrate up based on reaction and side effects.
When, if ever, do you consider prescribing clozapine after only one unsuccessful antipsychotic trial in schizophrenia?
I have read a recent JAMA Psychiatry paper concerning clozapine initiation after 1 antipsychotic trial, which was not successful (Li et al., PMID 41811299). I have not changed my practice, which is to require 2 such trials (which blood level confirmation to eliminate non-compliance) before prescribi...
How do you manage sleep disturbances in patients with Alzheimer’s disease without relying heavily on deliriogenic medications?
Sleep disturbances are common in older people and in those with Alzheimer’s disease (AD) in particular, and there are often multiple etiologies. Whether sleep disturbances increase the risk for AD, or are a result, metanalyses have suggested that the magnitude of sleep impairment correlates with the...
When do you consider the use of N-acetylcysteine (NAC) in patients with trichotillomania?
Great question! NAC comes up frequently in clinical discussions of trichotillomania, and it's worth being clear-eyed about what we actually know. NAC restores extrasynaptic glutamate homeostasis via the cystine-glutamate antiporter (system Xc⁻), which increases tonic activation of presynaptic mGluR2...
How long do you continue benzodiazepines in patients who have recovered from catatonia?
As others have already responded, it is case-dependent. In an otherwise healthy patient whose underlying medical or psychiatric condition causing catatonia had stabilized, there is likely a way to gradually taper off benzodiazepines without a risk of relapse.However there are other cases that are mo...