Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do manage transient post-ECT symptoms like irritability, tearfulness, or panic attacks?
Transient emotional symptoms after ECT are fairly common, particularly in the first 30-90 minutes after treatment and during the recovery period. Although the literature focuses more on confusion, headache, and myalgias, many experienced ECT psychiatrists report seeing brief episodes of irritability...
How do you counsel patients on the risks and benefits of antidepressant use during pregnancy?
I always frame the decision as being between the risks and benefits of the medication vs. the underlying condition. We are always aiming for the "minimum effective dose" but "effective" is just as important as "minimum." Medications are, of course, not the only way to treat psychiatric illness and a...
How do you handle requests from patients to complete medical paperwork that falls outside your scope of practice when they cannot access their other clinicians?
These requests are relatively common and can come from the patient, a healthcare institution, or another institution, such as an insurance company or school. A subtype is the forensic document, which can come from an attorney, a local state, or a federal agency. At times, law enforcement agencies ma...
When do you consider using olanzapine/samidorphan?
I prefer to use olanzapine/samidorphan combo in mildly obese patients when I decide to start olanzapine, and the patient does not have the info and skills yet to work on self-care. Unfortunately, there is still some weight gain on this combo, but at least not the usual 20-30 or even more in olanzapi...
How do you differentiate major depressive disorder from baseline functioning in patients with intellectual disabilities?
A general assumption of psychiatry is that people with intellectual disabilities can be afflicted with nearly any of the psychiatric disorders apparent in the general population. However, making the diagnosis of other psychiatric disorders in people with varying degrees of intellectual disability an...
What is your approach to delayed or inhibited ejaculation related to SSRI sexual dysfunction?
There are several theoretical possibilities that have been suggested over time. Periactin 4mg 30 minutes prior to sex is noted as a possible intervention. I've never seen any benefit from this. Another possibility is to add Wellbutrin at regular dose which allows for additional sympathetic nervous s...
What is your approach to augmenting treatment for depressive disorders in those continuing to take a tricyclic antidepressant at baseline due to historical effectiveness?
Depends on the risk of suicidality. If there is any history or any hint of a possibility of it, I do not continue with a TCA. I would augment with a dopamine agonist. I only use TCA to help with multiple comorbidities, such as migraines, insomnia, neuropathic pain, along with depression - knowing I ...
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 distinguish cannabinoid hyperemesis syndrome from cyclic vomiting syndrome?
When you are seeing a patient with intractable vomiting, this is a good time to slow down and take a thorough history. Often, patients can provide key pieces of information that help you distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS). CHS typically occurs in y...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous