Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel elderly patients who demonstrate mild cognitive impairment but do not meet the criteria for a neurocognitive disorder?
I would let them know that mild cognitive impairment (MCI) is an umbrella diagnosis with many different contributing factors as well as risk factors for progression to dementia. Control what you can control. Limit contributing factors such as pain, mood, and sleep optimization, as well as limiting a...
What recommendations do you have regarding the use of dronabinol to prevent cannabis withdrawal in an inpatient medical or psychiatric setting?
I routinely use dronabinol in patients who are heavy/daily cannabis users and are having a hard time as inpatients with any degree of withdrawal and cravings. It can be a good anxiolytic as well as antiemetic and orexigenic in this situation. Depending on their preferences, it can be scheduled with ...
When do you recommend HLA testing prior to prescribing lamotrigine, carbamazepine, or oxcarbazepine to patients of Asian descent?
This is one of the few actionable tests to avoid the more frequent occurrence of DRESS (Drug Rash with Eosinophilia Syndrome) or SJS (Stevens-Johnson Syndrome). Practically speaking, it is unusual for clinicians to have these HLA tests available in a fashion timely enough to match the usual need for...
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’ ...
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...
How do you manage sleep disturbances in patients with Alzheimer’s disease without relying heavily on deliriogenic medications?
Sleep disturbances are common in older people and in those with Alzheimer’s disease (AD) in particular, and there are often multiple etiologies. Whether sleep disturbances increase the risk for AD, or are a result, metanalyses have suggested that the magnitude of sleep impairment correlates with the...
What is your approach to Tardive Dyskinesia when VMAT2 inhibitors are ineffective or unaffordable?
In established cases of tardive dyskinesia, in which withdrawal-emergent dyskinesia has been ruled out, and dyskinesia has persisted despite a sufficient washout interval after removal of the offending agent, VAM2 inhibitors such as valbenazine and deutetrabenazine are used for pharmacotherapy. If t...
How do you manage patients with low vitamin D levels in your psychiatry practice?
Low vitamin D levels are especially common in winter and early spring because we make endogenous vit D from 7-dehydrocholesterol in the epidermis only when UV light falls directly on the skin. If we have applied sunscreen, little or no vit D will be made. Since we venture outside in the late fall, w...
How do you approach a treatment relationship with a patient who is non-adherent to recommendations and also is not interested in transfer to another practitioner?
This situation superficially forces a provider to sit with frustration and perhaps resentment versus skirt the issue of abandonment. Some would (or would wish to) choose the latter and be ethically content to follow rules about providing referral information and a "buffer" period of continued care w...
How have you incorporated wearables such as fitness trackers, smartwatches, or sleep monitors into your practice?
While pulse may be accurate on some devices, blood pressure and sleep data are notoriously inaccurate, and I would not include those. There is a great Curbsiders podcast about hypertension and measuring blood pressure properly that addresses the disadvantages of wearables for this purpose.