Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
How do you titrate lithium for patients with bipolar affective disorder during pregnancy and immediately after delivery in the context of fluid shifts and changing levels?
Great question! Lithium clearance increases during pregnancy, and some women may require a dose increase to maintain therapeutic benefits. It is not my practice to prophylactically increase the dose during pregnancy, but I do recommend monitoring labs (lithium level, BUN and creatinine, and TSH) ea...
How do you differentiate postpartum psychosis from postpartum obsessive compulsive disorder?
This is a fantastic question and one that arises frequently in my clinic. There are a couple of cases, but the simplest and most common distinction is awareness of the unreasonable nature of their intrusive thoughts in OCD, while postpartum psychosis is typically paired with a belief in delusional c...
Below what eGFR would you consider discontinuing lithium in a bipolar disorder patient with chronic kidney disease?
It seems nowadays we have other effective therapy besides lithium for the treatment of bipolar disorder. I tend to stop lithium as soon as I get a sense that there is a decline in kidney function as to avoid further damage. Of course, all of this depends on the specific situation and other possible ...
Which interventions have you found effective for managing sensory sensitivities in children with autism spectrum disorder?
Sensory sensitivities are very common in ASD and are listed as one of the four aspects of the core symptoms under the restricted, repetitive behaviours, interests or activities criteria of the DSM-5. Depending on the sensitivity, therapeutic interventions can be designed and implemented by occupatio...
Do you avoid triptans in patients on SSRI's due to the potential risk of serotonin syndrome?
I feel very comfortable using triptans with SSRIs/SNRIs. In 2010, the American Headache Society released a position statement on this very issue:Evans et al., PMID 20618823Their position is that the available evidence does NOT support the claim that triptans should not be used with SSRIs or SNRIs.A ...
Do you taper memantine after completion of 24 weeks of therapy?
Tapering is recommended when discontinuing some medications used in the management of dementia such as cholinesterase inhibitors. There are anecdotal cases of “discontinuation syndrome” after abrupt cessation of memantine in patients with dementia. However, this alone does not prove that a slow tape...
How do you approach a patient who exhibits classic bipolar symptomatology (including cycling sleep changes, behavioral changes, and mood changes) but has never responded to any form of adequate trials of mood stabilizer treatment?
I would question the diagnosis and look to better understand underlying anxiety, PTSD, or borderline personality disorder. I tend to see this in patient who have substantial trauma history. I look to treat the comorbid symptoms (insomnia, substance abuse, treating ADHD with an alpha 2 agonist, treat...
What is your approach to using ketamine for agitation in the ED setting?
The use of ketamine for agitation in the ED setting is not without controversy. Some clinicians feel that it is an essential tool for the management of agitation, while others feel that the potential risks outweigh the benefits. If ketamine is going to be used to treat agitation, appropriate patient...
How do you approach the psychiatric symptom management of Huntington’s Disease?
The neuropsychiatric features of Huntington's disease are not as consistent as the motor or cognitive features. Still, they can cause substantial disability, be prominent early in the disease, and even occur as initial features. The majority of Huntington’s disease (HD) mutation carriers experience ...