Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What do you do if a patient with ADHD on dexamfetamine for many years develops Alzheimer's disease?
The issue with the diagnosis of ADHD is that adult-onset ADHD particularly, in my opinion, has major validity problems including a wide differential diagnosis, with no biomarkers. Also, it is now thought that Alzheimer's disease has a long prodrome (15-20 years) from being asymptomatic to having pro...
How do you approach antidepressant choices for patients with generalized anxiety disorder when the patient reports excessive sedation on low doses of SSRIs?
We forget that bupropion, despite systemic misconceptions, has a very good anxiolytic effect. It is the darling of the centers treating refractory anxiety disorders.
How do you approach the use of buprenorphine/naloxone in pregnant and breastfeeding patients?
If the patient is already on it, many doctors, including myself as an addiction psychiatrist, will simply switch to the same dose without the naloxone component, just to use the minimum necessary meds while pregnant. It’s not a hard and fast rule though. The dose may need titration later in pregnanc...
What are your perspectives on using GLP-1 agonists as a primary or adjunctive treatment in psychiatric care?
It does not appear that that class of medication could be a primary treatment option at the moment. There is a significant new and emerging body of information indicating that the use of these medications could be very useful and therapeutic potential is sizable. Given that the majority of our patie...
How frequently do you recommend EKGs in pediatric patients on antipsychotics, especially in patients taking antipsychotics with more QTc risk?
AACAP recommends baseline EKGs only in patients with a family history of cardiac problems (sudden cardiac death in young/arrhythmia in close relatives), personal or family history of arrhythmia/other cardiac abnormalities, personal history or symptoms including syncopal attacks, and palpitations to ...
What do you do when a patient experiences multiple rounds of antidepressant-related tachyphylaxis?
Our clinic is having remarkable success with TMS for those patients.
How do you manage MAT for opioid use disorder in lung transplant patients during the peri/postoperative period?
There is currently no evidence regarding mOUD in lung transplants. Available research represents generally a weak quality of evidence regarding opioid use for pain control before and after lung transplant. Non-opioid analgesic interventions, including thoracic epidural anesthesia and intercostal ner...
Do you still consider changing atypical antipsychotics that are working well in children undergoing puberty if the prolactin levels are high but there are no symptoms of drug-induced hyperprolactinemia?
I consider the risk of osteoporosis if I believe it may be used long-term, even if asymptomatic. Typically, I warn parents of the risk but continue the medication if the prolactin is only mildly elevated. I find it rare to find an adult patient who is taking the same drugs they did in adolescence. L...
When do you decide to use liothyronine (T3) for augmentation in treatment for treatment-resistant depression and how do you implement it?
The starting dose is between 5 and 25 mcg daily, and it escalates every 2-3 weeks but only after lab f/u results. Baseline FT4, T3,TSH and f/u labs. Avoid suppressing TSH excessively, to prevent osteoporosis.
What do you do for patients who have received accidental extra dosages of long-acting injectable antipsychotics?
Close monitoring, any EPS, one repeat EKG in a few days, reporting this to the family so that they are aware of the patient getting an extra dose, and cutting down or stopping any oral anti-psychotics to mitigate risk are some of the things I would do. There is no clear protocol on this, unfortunate...