Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you treat patients with comorbid Bipolar Disorder and ADHD?
I usually start with non-stimulant medications, guanfacine (or clonidine) being my first choice. I'll move to bupropion or amantadine after that. I've had good results with amantadine and not much luck with atomoxetine (I find more problems with nausea and high blood pressure than benefits with that...
How do you manage tacrolimus-related psychosis?
The mechanism of tacrolimus-related psychosis is unclear, but some papers have suggested that calcineurin (which is involved in the regulation of dopaminergic, glutamatergic, and GABAergic systems and implicated in psychotic disorders) may play a role (1). As a result, antipsychotics are often a mai...
Do you warn patients about suicidal ideation when starting anti-seizure medications?
Yes. I always discuss with every patient the FDA's warning on increased risk for suicidal ideation and behavior when I start an antiseizure medication (ASM). Here are the reasons: Nowadays, patients go to the internet and review the adverse events of prescribed medications. In the case of ASMs, the...
How do you approach neuromodulation in postpartum depression?
TMS has been researched for PPD and there is a lot of literature on this on PubMed. Our practice was actually involved in a real-world study and we saw good results. Very safe to use considering it is not a systemic therapy. However, it is important to recognize a couple of nuances. First, postpartu...
What do you consider when selecting an antipsychotic medication for acute agitation?
There are several factors to consider when choosing an antipsychotic (or any) medication for the treatment of agitation. These factors include availability (can I get it at my hospital?), route of administration (do I want/need to give a medication PO vs. IM vs. IV?), onset of action (do I need this...
How do you counsel patients on vaping cessation as compared to smoking cessation?
Presently, evidence-based approaches to vaping cessation are not well-developed. Thus, one should approach nicotine vaping cessation in a similar way to tobacco smoking cessation using a stepped care approach. Motivation to quit (versus reduce) use should be assessed and motivational counselling tec...
How do you manage antipsychotic-induced prolactinemia?
Most patients treated with standard doses of risperidone and paliperidone will develop hyperprolactinemia, typically below 100 ng/ml. However, not all individuals with elevated prolactin levels will exhibit clinical symptoms such as erectile dysfunction, galactorrhea, or irregular/absent menstrual c...
What do you use for treatment-refractory anxiety where trials of antidepressants have not worked either from ability to tolerate or inadequate effect?
I find gabapentin to be very helpful for anxiety. Other agents I've found helpful include the alpha-2 agonists clonidine and guanfacine, which I've found particularly helpful for people with trauma-related anxiety and anxiety with somatic symptoms. Both are also helpful for nightmares. Regarding ga...
What is the best treatment for treatment resistant restless leg syndrome?
In general, when a condition is considered “treatment resistant”, it is useful to reconsider the diagnosis, assess the quality of the patient-doctor relationship, identify potential sources of treatment resistance, and identify multiple non-pharmacological approaches to addressing symptoms.
How do you address/manage the recreational use of dextromethorphan (sometimes called "robo-tripping") that has risen to the level of use disorder?
This problem of "robo-tripping" has become an increasingly observed clinical issue, namely the misuse of dextromethorphan with cough medication (Robitussin). This is often in conjunction with alcohol misuse. We recently published a case report in The American Journal of Drug and Alcohol Abuse (Ledwo...