Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your experience with metformin for improving cognitive impairment in schizophrenia?
I have not found that it does much. But there was a recent promising study for using TMS on a particular brain region that is hopeful.
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...
How do you differentiate Down syndrome disintegrative disorder from Alzheimer’s disease?
The short answer is that it may not be possible. Down syndrome disintegrative disorder, although not fully validated, is a developmental regression in children with Down syndrome and is thought to be characterized by a loss of previously acquired adaptive, cognitive, and social skills in individuals...
What would be your approach to managing social anxiety in teenage patients with ADHD, doing well in regards to academic functioning with their stimulant medications?
Good question! So when the potential for comorbid diagnoses is raised, I take a step back. Some kids with ADHD become (appropriately) self-conscious and behaviorally inhibited in the academic environment due to their off-task behaviors, reduced academic performance, and challenges with basic behav...
How will you use xanomeline-trospium (KarXT, Cobenfy) for patients with schizophrenia?
KarXT, an investigational drug for schizophrenia developed by Karuna Therapeutics, combines xanomeline and trospium and is currently under FDA review. Unlike traditional antipsychotics that work by blocking post-synaptic dopamine receptors, xanomeline functions as an agonist at M1 and M4 receptors. ...
When and how do you taper antipsychotics after a resolved episode of bipolar mania with psychotic features?
At times, I have worked with patients to taper antipsychotics even in the absence of current side effects due to their concerns about long-term side effects (dyslipidemia/weight gain and TD, mostly). This is most often my strategy when folks are ambivalent about medications in general and don't like...
How do you approach pain management needs for patients well-established on buprenorphine/naloxone?
Buprenorphine has high affinity but low activity at mu receptors, and as a result, buprenorphine provides limited analgesia and will not likely provide adequate relief of severe pain in most patients.Continue suboxone treatment. In case of acute pain, consider oxycodone 5 mg tabs, 1-2 q 4 hours as n...
What or where is the best reference guide for managing patients with bipolar disorder who are on meds and want to become pregnant?
Great question! There are a few resources that I find particularly helpful for both patients and providers. The MGH Center for Women's Mental Health Website, https://womensmentalhealth.org/, is a great resource for both patients and clinicians alike. There are speciality specific pages, including o...
What is your approach for managing persistent psychotic symptoms of a hallucinogen-induced persisting psychotic disorder?
There are two types of HPPD: type 1 (flashbacks only) and type 2, with the complex of visual symptoms elsewhere described. It seems to be due to disinhibition in visual processing in the occipital lobes. Interesting description here: The Mysteries of HPPD, both of which have demonstrable efficacy in...
What do you do if a patient with ADHD on dexamfetamine for many years develops Alzheimer's disease?
The issue with the diagnosis of ADHD is that adult-onset ADHD particularly, in my opinion, has major validity problems including a wide differential diagnosis, with no biomarkers. Also, it is now thought that Alzheimer's disease has a long prodrome (15-20 years) from being asymptomatic to having pro...