Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to managing hallucinations in dementia?
One thing to remember is that hallucinations are not always disturbing to the patient, but to the caregiver! If the patient is fine with seeing a little girl or dog (often in LBD), the family just needs to be educated to let it go. They don’t need to AGREE that the hallucinations are present; they j...
Have you used amantadine off-label for DMDD in children or adolescents?
Has been useful with aggression and severe mood dysregulation that SSRIS do not help and it has less side effects than SGAs.
How do you implement antipsychotics in the management of agitation in Alzheimer’s patients?
The answer to how you implement antipsychotic medication in the management of agitation in a patient with Alzheimer's dementia involves several steps, outlined here: Ensure the agitation is not related to an acute medical condition and/or delirium. In this case, it is important to treat the underlyi...
How do you assess and adjust treatment in patients who develops hypothyroidism after being on lithium for several years?
It depends on whether the patient is symptomatic. If not, careful monitoring is all that is needed. If there are significant symptoms, treatment with levothyroxine would be needed. Continued use of lithium is appropriate if it has been effective over time.
Would you consider over-the-counter dextromethorphan (low dose, slow titration) as augmentation in MDD?
Just one comment to clarify what might be a title/question mismatch:Augmentation of bupropion with dextromethorphan makes sense, given the positive results from the bupropion/dextromethorphan polypill. As to results, I'll leave that to others, as I haven't used this strategy very often.Augmentation ...
Do you consider using buspirone for the management of anxiety in older patients?
While buspirone has been FDA-approved for the treatment of generalized anxiety disorder (GAD) and for short-term relief of anxiety symptoms in general since the 1970s, it is not generally considered a first-line treatment, despite its low misuse potential as a non-benzodiazepine. There are no large ...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
How do you counsel patients who are hesitant to try behavioral therapies for insomnia instead of starting a sleep medication?
I try to be very understanding of the desire to have an easier solution to sleep difficulties, which are so common. It is challenging that our gold standard and best strategies to help people sleep better require a lot of effort on the patient's part. Starting with that validation can be very helpfu...
When do you order brain imaging in young adults presenting with first-episode psychosis in the absence of clear neurologic red flags?
You should always consider brain imaging, at least at CT, in the first episode of psychosis. While this will be negative almost 99% of the time, it's always good to rule out that population that may have something else going on in the brain that we can actually attribute the psychosis to. Also, chec...
Considering that ADHD symptoms must be present in 2 environments for accurate diagnosis, how do you reconcile a teacher Vanderbilt that shows no indication of ADHD symptoms when the parent Vanderbilt and clinical interview indicate ADHD symptoms?
There are a number of reasons you may have a discrepancy between reports from home and school. Some private schools have very small class sizes, and teachers give a lot of individualized attention, which might mitigate symptoms. In other schools, the class size may be so large or the teachers so inc...