Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do you attribute tremors to lamotrigine?
Not a side effect of LTG, but tremors are common and patients love to attribute everything to medications.
How do you approach prescribing stimulants for ADHD in patients who are concurrently using cannabis?
Directly confronting cannabis use in ADHD assessments usually just makes patients defensive. Instead, I use a Motivational Interviewing approach, letting education do the heavy lifting early on. During the evaluation, I explain how THC products can heavily mimic and worsen core ADHD symptoms. Patien...
How do you manage obsessive-compulsive symptoms secondary to clozapine?
You have to find a good balance, which can be very challenging if the psychosis and OCD are prominent. Clozapine exacerbates OCD the most out of any antipsychotic. You can use Luvox to help boost clozapine levels and decrease norclozapine levels, which is the main culprit of metabolic side effects; ...
How do you approach titration or transitioning to Cobenfy in patients currently on an antipsychotic?
Antipsychotics with significant anticholinergic activity, such as olanzapine and clozapine, can add to the effects of trospium contained in xanomeline-trospium combination. Product labeling reads "Concomitant use of COBENFY with other antimuscarinic drugs that produce anticholinergic adverse reactio...
When do you check vitamin D levels in patients with depressive symptoms?
I routinely check 25-OH D in all my patients. Given that half the population is deficient and that we now know the role of vitamin D not only for bones but in mood, cognition, and immunity. We need to be aware of deficiencies and replete if low. Moreover, ideal levels are 60-80, not just over 29 as ...
When do you consider using dextromethorphan–bupropion for the treatment of depression?
The data support a rapid antidepressant effect given the NMDA activity that is different than monoamine activity of all other antidepressants. Within a week, many patients I treat notice a benefit and this continues to improve for several weeks. The general guidelines would suggest Auvelity be a sec...
When, if ever, do you consider increasing Adderall above the FDA-approved maximum daily dose of 40 mg for adult patients?
I titrate the dose based on the patient's needs, functioning, and tolerances.
Which patients do you think would benefit most from xanomeline-tropsium (Cobenfy) monotherapy?
What we know best about this new drug, Cobenfy, a xanomeline-trospium combination, is that it does not directly affect the dopamine receptor, so it is novel and a new antipsychotic drug. And its antipsychotic efficacy has been demonstrated and accepted by the FDA. But still, we have a rather ‘pure’ ...
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...
How do you counsel patients who are interested in using kratom for chronic pain management?
I am not a pain management expert, but would recommend against use for chronic pain management. Risks outweigh in a significant order. It's not FDA-approved for any form of pain treatment. There is no dosage reference to use. The pain control one gets may be too low compared to the addictive risks, ...