Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Is it possible to develop worsening motor features of Parkinson's disease (PD) when using clozapine (for treatment of PD psychosis) above a certain dose?
Clozapine does not appear to worsen Parkinson's disease at most doses used for patients with PD. Other side effects are dose limiting such as orthostatic hypotension and sedation. The challenge of blood monitoring has limited the use of this drug in the US.There is a wonderful podcast on movementdis...
What is your approach to using apremilast for psoriatic arthritis in patients with history of depression?
Depression is a common comorbidity of psoriasis and psoriatic arthritis (20% at least mild and 14% at least moderate in a recent meta analysis). Depression is a known but relatively infrequent side effect of apremilast (<1.8% in clinical trials). It is important to screen for depression in all patie...
How would you manage a patient with secondary progressive multiple sclerosis manifesting with increased neuropsychiatric manifestations (ex. psychosis) with no recent changes on brain MRI?
Exclude the usual suspects such as infections, electrolyte abnormalities, and polypharmacy. If nothing pans out and nutritional causes or deficiencies have been excluded I would direct such patients to psychiatric care. I will also make sure that the patient is not suicidal by doing a Beck Depressio...
How do you approach the workup and management of patients with suspected functional neurologic disorders?
This is not really an answerable question. I would re-frame the question, because it really depends on the kinds of symptoms they have and the neurologic exam that is performed. I disagree with neurologists who say that "functional neurologic disorders" are a diagnosis of exclusion. That is absolute...
How do you approach treating patients with delusions of parasitosis who can not tolerate an antipsychotic?
I continue to switch them until I find one they can tolerate. My typical approach is Abilify 2 mg daily and increase by 2 mg every other week until on 10 mg daily if tolerable. If they can’t tolerate that, then I switch to Risperdal and if they can’t tolerate that then I switch to pimozide. If they ...
How do you approach NSAID use in patients on SSRIs?
This is a good question, the combined RR for NSAID+SSRI/GI complications is ~12. I generally avoid the combination and utilize topical NSAIDs if possible. I also discuss the possibility of switching patients from a 'traditional' SSRI to duloxetine, which is FDA approved for the treatment of primary ...
Do you use pimavanserin to treat psychotic symptoms in Lewy body dementia?
Yes, if insurance allows. However, it is my medication of last resort after trying cholinesterase inhibitor and SSRI. It can be used in the place of quetiepine. Note that this is an off-label use of the medication.
How do you manage patients with dementia who require but cannot tolerate an aquaplast mask for radiation therapy?
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Would you avoid the use of keppra in patients with TBI due to concerns for worsening agitation?
I suspect that this practice of prophylactic antiepileptic medications for TBI patients will go away over time. History has shown us time and time again that we over-medicate patients.
What is the best way to manage severe claustrophobia and anxiety for Thermoplastic masks?
I’ve found that P.O. uptake of benzodiazepines is notoriously unreliable, and often the severity of patients’ anxiety isn’t apparent until after the process has begun. Because of this, I stock IM hydroxyzine (a.k.a. Atarax or Vistaril), which is a great non-narcotic old-school anxiolytic with a reli...