Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you consider using phenobarbital over symptom-driven alcohol withdrawal protocols for patients at low-to-moderate risk of withdrawal complications?
While traditional frameworks often reference "low" or "moderate" risk for alcohol withdrawal complications, in clinical practice we find it more useful to focus on the treatment setting and validated predictors of severe withdrawal rather than subjective risk labels. Phenobarbital is increasingly us...
How do you decide whether to start MAT for opioid use disorder during hospitalization?
There are several considerations when approaching patients about MOUD. In general, every patient should be offered MOUD during their hospitalization because every admission represents an opportunity towards substance recovery. With that said, I don’t entangle substance use treatment with their medic...
In a woman with bipolar disorder with a menstrual component would lamotrigine itself worsen the condition given that it interacts with prescribed estrogen?
Very unlikely. Estrogen can cause a lowering of the Lamictal serum levels and not vice versa. So, if a patient on Lamictal is put on an estrogen product, there may be a need to increase the dose of Lamictal.
What parameters do you follow to avoid rebound effects when using clonidine only for nightly or daily as-needed indications?
I use a fair amount of clonidine in my practice, and I haven't found any rebound blood pressure effects for people who take clonidine nightly or for PRN use. In fact, I've stopped routine practice of checking blood pressure for those who are not taking a standing daily dose. I worry about rebound mo...
How do you approach managing clozapine in patients who are critically ill?
With COVID-19 disproportionately affecting those with mental illness we found an increasing number of medical admissions for those on clozapine. There are multiple domains of concern for those on clozapine who are medically ill. Clozapine levels have been shown to potentially double during periods o...
What is the role of inpatient psychiatric or psychological evaluation in patients who have had acute function change as an inpatient?
This is an important question. An acute change in function is a frequent reason for hospital admission and must be considered as a feature of some underlying medical, neurological, or psychiatric condition. It is important to know what functions have changed, including basic and instrumental activit...
How do you approach treatment-refractory schizophrenia which has not responded to multiple antipsychotic trials including clozapine?
I would also add that there are now case reports and case series of the ketogenic diet having significant benefits for the treatment of refractory schizophrenia, including some cases of those who had not benefitted from clozapine. The mechanisms of action by which a ketogenic diet improves brain hea...
How do you manage nausea side effects in patients on cariprazine?
Have them try taking it every other day. This can offset side effects, given the long half-life.
How do you manage emotional blunting due to SSRIs/SNRIs?
As with other classes of psychotropic medication, I have found that even though two medications may be in the same class, a particular patient may experience different responses to them, both in effectiveness and/or side effects. So, if that occurs, I will often try another medication in the same cl...
Other than clozapine, what antipsychotics do you use in a manic or psychotic patient with TD?
Lumateperone is quite all right with minimal D2 involvement. But don't forget the blocking of VMT.