Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you order brain imaging in young adults presenting with first-episode psychosis in the absence of clear neurologic red flags?
All the time.
How do you transition severely agitated ICU patients off a dexmedetomidine infusion when it is being used primarily for psychiatric agitation?
Even if initial agitation is felt to be psychiatric, it is important to remember (and remind involved teams) that following intubation and sedation in the ICU, rebound agitation as dexmedetomidine is weaned may have become multifactorial. As such, interventions such as monitoring for contribution fr...
How do you approach buprenorphine dosing and titration in older adults with opioid use disorder?
It's important to remember that there is no such thing as "opiate use disorder". There is certainly addictive/compulsive use of opiates, as with alcohol, gambling, eating, or exercising. These are all compulsive psychological symptoms that are often substituted for one another. To label each differe...
Which cognitive screening tools do you use when evaluating older adults with suspected dementia?
In keeping with Alexander Luria's (paraphrased) maxim that knowing what a patient gets wrong on cognitive screening is incomplete until you know why/how they erred, I'd say the tool used is less important than interpreting it. So, I don't worry too much about MMSE vs MoCA vs SLUMS (as long as the MM...
What pharmacological management do you consider for self-injurious behavior in patients with autism spectrum disorder?
This is a great question but requires a nuanced answer. It all depends. In short, what I think the clinician needs to know is whether the patient with ASD and self-injury has a treatable condition that is driving self-injury. Perhaps the most critical is whether the patient has a medical problem tha...
What opportunities do you see for combining xanomeline-tropsium (Cobenfy) with other anti-psychotic agents?
The opportunities of combining Cobenfy with any of our other antipsychotic treatments, in my opinion, are unlimited. This is one of the most important aspects of its drug use that has NOT been systematically tested. One might think first of combining Cobenfy with a widely used drug, like risperidone...
How do you counsel patients who want to understand why sublingual cyclobenzaprine works to relieve their fibromyalgia pain and other related symptoms?
I like to set the stage with patients and make sure they clearly understand the link between sleep disruption and pain sensitivity, particularly in the context of central pain and fibromyalgia. One of my rheumatology attendings during fellowship used to explain this using classic sleep research from...
In children with unknown family cardiac history, do you require a routine EKG prior to starting a stimulant?
The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) have stated that ADHD medications have not been shown to cause heart conditions or sudden cardiac death, although stimulant medications do increase heart rate and blood pressure. By increasing sympathetic nervous syste...
When, if ever, do you consider using dronabinol to treat agitation in dementia?
Dronabinol should be considered for treating agitation in dementia when non-pharmacological interventions and standard pharmacological options, such as antidepressants or antipsychotics, have failed or are poorly tolerated. I have a handful of patients in my practice who fit that scenario and benefi...
What are the most effective strategies for managing weight gain associated with antipsychotic medications?
In my experience, the following things have worked. Reassurance that it is a medication side-effect. Consider switching the anti-psychotic (or at least try and decrease the dose of the antipsychotic). Aripiprazole, Caplyta (Lumateperone), and Vraylar (Cariprazine) have shown benefits vis a vis weig...