Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you determine the treatment course of esketamine or IV ketamine when used for treatment-resistant major depressive disorder?
Selection for esketamine vs intravenous ketamine is often a reflection of both clinical factors and practical/logistical factors. Practical factors may come into play first as some insurance may cover one modality over the other in which case the decision is relatively straightforward. Also, current...
Do you tend to avoid the use of oral weight loss stimulant medications such as phentermine in obese patients on SSRI or ADHD treatments?
I generally avoid phentermine (or similar weight management stimulant medications) in patients taking other stimulants for ADHD. I have used this class of medications together with SSRI and SNRI medications with monitoring. In theory, there may be risk for interaction including possible serotonin sy...
In your outpatient practice, which antidepressants do you most prefer for treating depression in older adults?
This is quite a broad question. Too many factors decide preferences in older adults with MDD or TRD. Symptoms profile - MDD is incredibly heterogeneous Prior treatment trials - drug, dose, duration, failed or not tolerated Current medical status and current medication list - drug interaction is mor...
How do you work psychodynamically with a child whose somatic complaints increase in response to parental marital conflict?
This particular situation might respond well to structural family therapy. Salvador Minuchin wrote and modeled interventions that resulted in changes in the family system after addressing the connection between the symptoms in the child and the conflicts in the family. Changes usually happen after f...
How do you manage REM sleep disorder in geriatric patients with dementia associated with periods of catatonia?
Melatonin helps with REM sleep behavior disorder in most but not all cases - a trial-and-error process. Antipsychotics may not help with REM sleep behavior disorder (in fact, promoting slow-wave sleep worsens REM sleep behavior disorder), but may help with catatonia if the etiology is psychosis (sta...
What pharmacologic treatments have you found helpful in treating comorbid schizophrenia and OCD?
This diagnostic combination is sort of the inverse of the "schizo-obsessive" type of OCD, where the patient has probably started with SSRIs or clomipramine and we're adding atypicals or typicals for the psychotic elements that emerge. For someone with idiopathic psychosis chronically, they may alrea...
What strategies have you found helpful for balancing telehealth and in-person appointments to reduce bottlenecks?
I don't have any bottlenecks. I have an office close to home, so I can come and go at will. I also have a small practice, and I am no longer open to new patients.
In your experience how does the dose of Remeron (mirtazapine) influence side effects like hunger and weight gain?
Mirtazapine will have a more severe occupancy on histamine receptors at the lower doses. That is why we use 7.5 mg as a hypnotic. As you increase the dose, there is also more norepinephrine being produced.
How do you handle elevated blood calcium levels from lithium?
Lithium in the past would often show up as calcium on blood tests, leading to an artificially elevated level. I don’t know if the modern tests have fixed that. Usually, I will watch it if over time the calcium is only mildly elevated, or refer for further workup (such as parathyroid issues, bone iss...
How do you manage clozapine related sedation for patients who have treatment resistant Schizophrenia and otherwise had good response to clozapine?
I have colleagues who use modafinil to address the daytime sedation. I've only tried this once, and the patient had intolerable headaches from the lowest dose of modafinil, so I can't say that I've used this successfully. Strategies I've used with other sedating meds include taking the medication e...