Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
What approaches have you found most helpful for concurrent severe major depressive disorder and alcohol use disorder?
I'm a strong believer in AA for alcoholics, to address the addiction and also the depression, as the social support offered there can be very helpful. A person agreeing to "work the steps" with a sponsor has more in-depth character restructuring and available support than most therapists can provide...
What is your medication of choice when considering outpatient alcohol withdrawal management (diazepam vs chlordiazepoxide vs lorazepam)?
While benzodiazepines such as chlordiazepoxide, diazepam, and lorazepam remain the mainstay of treatment for acute alcohol withdrawal syndrome (AWS), their use in the outpatient setting is generally inappropriate for patients with Alcohol Use Disorder (AUD)—except in narrowly defined, low-risk scena...
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 ...
In your clinical experience, has T3 augmentation been effective for treatment-resistant depression?
I have used T3 as Cytomel for this purpose, after hearing Dr. Lee Cohen describe his research on the subject. However, over time I have found that simply using thyroxine, which I think is a mix of T3 and T4, for augmentation works about as well. The response, as I recall, to either one has been mean...
How do you approach the use of benzodiazepines in patients with chronic medical illnesses that may be susceptible to respiratory compromise (e.g., CHF, COPD, ILD)?
It’s a very good question and answers may vary among different specialty providers. Yes, a slow or gradual weaning of the benzodiazepines would be advisable. When they reach lower doses the taper should be even slower over weeks or longer. There is a risk for not weaning them off benzodiazepines inc...
What medications do you prioritize or avoid in Parkinson’s Disease-related psychosis and behavioral disturbance?
From an evidence-based perspective, clozapine continues to have the most solid support for its efficacy in Parkinson's disease-related psychosis. Pimavanserin has FDA approval (albeit with some mixed data) specifically for this indication. Quetiapine and olanzapine are perhaps the most frequently us...
How do you distinguish cannabinoid hyperemesis syndrome from cyclic vomiting syndrome?
When you are seeing a patient with intractable vomiting, this is a good time to slow down and take a thorough history. Often, patients can provide key pieces of information that help you distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS). CHS typically occurs in y...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?
In our outpatient substance use disorder practice, we tend to use lisdexamphetamine (Vyvanse) at fairly high doses off-label for patients with meth withdrawal. We establish a buddy system preferably with someone who lives with them, provide Suicide hotline phone number, describe reasons to transport...