Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach antidepressant selection in patients with prolonged QTc?
In 2018, the American Psychiatric Association published a resource document on "QTc Prolongation and Psychotropic Medications," which was later followed up by a 2020 American Journal of Psychiatry publication: These manuscripts highlighted a few key points when making clinical decisions related to Q...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
How do you treat extrapyramidal symptoms secondary to anti-psychotic use in patients who have not benefited from cogentin or benadryl?
In general, when addressing motor symptoms from antipsychotics (or any dopamine-blocking agents including dopamine-blocking antiemetics), I find it useful to break things down more specifically than just EPS. This often will determine the agent that will be most beneficial. First Category: Hypokinet...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
How do you approach stimulant prescribing for ADHD when a patient has previously reported palpitations with stimulants but has a normal EKG off medication?
Get a cardiology consult and get a certificate about stimulant safety before initiating stimulants.
How do you manage withdrawal symptoms after stimulant discontinuation?
I have not witnessed bradycardia as a withdrawal symptom of stimulants at therapeutic dosages, although this is common with misuse/SUD. I have noticed increased behavioral and mood symptoms due to stimulant discontinuation, which may be related to shortages. I simply use whatever formulation is avai...
When do you use extended-release buprenorphine instead of daily formulations?
Extended-release buprenorphine (e.g., Sublocade, Brixadi) can be a good option for patients who have trouble staying stable on daily sublingual doses, especially those with adherence challenges, ongoing exposure to high-risk opioids such as fentanyl, or concerns about safety and diversion. Weimer et...
How do you evaluate and manage patients who report vivid, distressing dreams or “epic dreaming” that disrupt sleep quality?
Nicotine or nicotine replacement being used? (Very common cause) Varenicline (Chantix) for smoking cessation being used? (Known effect) Melatonin being used? (Possible, more likely with high/excessive doses) Recent reduction or cessation of an antidepressant resulting in REM rebound? (Known to cause...
What is your approach to recommending bright light therapy devices to patients with (seasonal) depressive disorders?
Bright light therapy has a strikingly positive evidence base for seasonal affective disorder, major depressive disorder, and even bipolar depression. I recommend shopping for a lamp with 10,000 lux, a large format, diffusion screen (possibly fewer headaches), and one that is on a stand so that it sh...
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...