Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you consider the use of clonidine in gabaergic withdrawal and how do you approach the risk of masking the autonomic signs of withdrawal when it is used?
There is limited and indirect evidence for the use of clonidine in "benzodiazepine-sparing" protocols for gabaergic withdrawal treatment. Generally, an anticonvulsant is used along with clonidine in this context. This "new" data recapitulates old, mainly European, studies combining beta-blockers wit...
What strategies have you found most effective for supporting weight loss in patients with bipolar disorder while minimizing the risk of mood destabilization?
If residual depressive symptoms are present, then the addition of bupropion is helpful. If the weight gain is deemed due to necessary psychiatric medication, then the addition of metformin often works. Of course, for the management of weight, diet and exercise need to be encouraged (in addition to t...
What medications would you consider for severe delusional disorder in a patient with RLS worsened by aripiprazole and quetiapine, who refuses clozapine?
Lyrica - better than gabapentin and will help with anxiety that might be brought on by delusional disorder. No FDA-approved medication for delusional disorder, and it may best be treated with gentle CBT for psychosis.
How do you manage patients with severe, refractory schizophrenia or schizoaffective disorder who need complex pharmacologic regimens but consistently refuse labs and ECG monitoring?
Document that the risks and benefits of the refusal were discussed with the patient, have the patient sign the refusal document, and then treat the patient without the labs and EKGs.
What approach to antipsychotics do you take with patients with primary thought disorder who are now geriatric?
The primary goal is to manage psychotic symptoms effectively while minimizing adverse effects, particularly those that may exacerbate cognitive impairment. Older adults may experience altered pharmacokinetics and pharmacodynamics, which can affect the efficacy and safety of antipsychotic medication...
How do you treat withdrawal symptoms from kratom addiction?
Consider buprenorphine for kratom addiction and withdrawal. I have seen patients developing kratom addiction in the context of trying to get off full agonist opioids. A variety of PRNs for symptom management (e.g., trazodone for sleep) can be helpful. I would also encourage counseling, overdose educ...
Would you consider changing management for a patient with bipolar disorder stable on an antipsychotic who is on anticoagulation after a recent PE or VTE?
Not necessarily, no. INR is followed regarding anticoagulation with warfarin, and can be adjusted accordingly to optimize INR.
Do you modify dosing or use of bupropion to mitigate seizure risk in patients without eating disorder who are restricting calories to lose weight?
No. The risk of seizures with bupropion is 0.1% with daily doses below 300 mg and 0.4% with doses up to 450 mg daily. The increased risk of seizures in eating disorders is due to higher risk of severe electrolyte disturbances that result from disordered eating, induced vomiting, and laxative abuse. ...
How do you discuss the mechanism and potential benefits of meditation with your patients?
What is the benefit of meditation practice? Thoughts and emotions are molecules interacting in a chemical solution called the human body. We cannot change a molecule that is already here, but when we change the chemical solution in which molecules of thought and emotion are arising, interacting, and...
How do you manage therapy cases where CBT techniques seem to increase distress or exacerbate underlying rigidity?
This is a very good question, but the answer depends, among other things, on the specific CBT techniques that are being utilized, which are contributing to the increased distress. A usual culprit is Exposure, often used for addressing phobias as well as traumatic past events. Most patients who seek ...