Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach a patient who exhibits classic bipolar symptomatology (including cycling sleep changes, behavioral changes, and mood changes) but has never responded to any form of adequate trials of mood stabilizer treatment?
I would question the diagnosis and look to better understand underlying anxiety, PTSD, or borderline personality disorder. I tend to see this in patient who have substantial trauma history. I look to treat the comorbid symptoms (insomnia, substance abuse, treating ADHD with an alpha 2 agonist, treat...
What is your approach to using ketamine for agitation in the ED setting?
The use of ketamine for agitation in the ED setting is not without controversy. Some clinicians feel that it is an essential tool for the management of agitation, while others feel that the potential risks outweigh the benefits. If ketamine is going to be used to treat agitation, appropriate patient...
How do you approach the psychiatric symptom management of Huntington’s Disease?
The neuropsychiatric features of Huntington's disease are not as consistent as the motor or cognitive features. Still, they can cause substantial disability, be prominent early in the disease, and even occur as initial features. The majority of Huntington’s disease (HD) mutation carriers experience ...
How do you manage tacrolimus-related psychosis?
The mechanism of tacrolimus-related psychosis is unclear, but some papers have suggested that calcineurin (which is involved in the regulation of dopaminergic, glutamatergic, and GABAergic systems and implicated in psychotic disorders) may play a role (1). As a result, antipsychotics are often a mai...
Do you warn patients about suicidal ideation when starting anti-seizure medications?
Yes. I always discuss with every patient the FDA's warning on increased risk for suicidal ideation and behavior when I start an antiseizure medication (ASM). Here are the reasons: Nowadays, patients go to the internet and review the adverse events of prescribed medications. In the case of ASMs, the...
How do you approach neuromodulation in postpartum depression?
TMS has been researched for PPD and there is a lot of literature on this on PubMed. Our practice was actually involved in a real-world study and we saw good results. Very safe to use considering it is not a systemic therapy. However, it is important to recognize a couple of nuances. First, postpartu...
What do you consider when selecting an antipsychotic medication for acute agitation?
There are several factors to consider when choosing an antipsychotic (or any) medication for the treatment of agitation. These factors include availability (can I get it at my hospital?), route of administration (do I want/need to give a medication PO vs. IM vs. IV?), onset of action (do I need this...
How do you counsel patients on vaping cessation as compared to smoking cessation?
Presently, evidence-based approaches to vaping cessation are not well-developed. Thus, one should approach nicotine vaping cessation in a similar way to tobacco smoking cessation using a stepped care approach. Motivation to quit (versus reduce) use should be assessed and motivational counselling tec...
How do you manage antipsychotic-induced prolactinemia?
Most patients treated with standard doses of risperidone and paliperidone will develop hyperprolactinemia, typically below 100 ng/ml. However, not all individuals with elevated prolactin levels will exhibit clinical symptoms such as erectile dysfunction, galactorrhea, or irregular/absent menstrual c...
What do you use for treatment-refractory anxiety where trials of antidepressants have not worked either from ability to tolerate or inadequate effect?
I find gabapentin to be very helpful for anxiety. Other agents I've found helpful include the alpha-2 agonists clonidine and guanfacine, which I've found particularly helpful for people with trauma-related anxiety and anxiety with somatic symptoms. Both are also helpful for nightmares. Regarding ga...