Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
In a frail older adult with depression unresponsive to two SSRI trials, what's your next step in management?
This is certainly a longer and nuanced conversation. Depends on the intensity of symptoms. Ensuring the diagnosis is accurate, reviewing the role of co-morbid cognitive disorders, organic issues masquerading as depression, and so on. Augmentation of an SSRI, e.g., mirtazapine, stimulating medication...
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
After remission from a first episode of psychosis how long do you continue antipsychotic treatment before attempting taper or discontinuation?
I don't think this is a one-size-fits-all question. This will depend on a number of factors. Probably most important is the client's attitude toward medication and their experience with it. Those who have done well with medication and have had no problems with side effects may be more comfortable co...
When is the best time to get a valproate level if a patient is taking Depakote DR once daily?
Levels should be obtained at steady state - which is 5 half lives. For ER formulation, figure about 5 days and it should be a trough level (immediately before the next dose).
How do you counsel patients with bipolar disorder who want to breastfeed?
This is a great question! Many women desire to breastfeed their babies, and providers often encourage the initiation of breastfeeding in the immediate postpartum period. For women with underlying bipolar disorder, this decision can be more nuanced. Nursing a young infant requires multiple feedings ...
How do you formulate and diagnose patients with chronic psychosis that developed after methamphetamine use but persists after cessation of use?
It may ultimately become schizophrenia that’s been unmasked by the stimulant use. I believe you need six months or maybe three months for a schizophreniform diagnosis, and then after that, it becomes schizophrenia if it meets all the other criteria. I have to check the DSM on the timeline.
When do you recommend neuropsychological testing in adults being evaluated for ADHD?
We should consider “testing” only when our main tool of diagnosis, a thorough psychiatric interview, history, and physical (mental status exam), demands more data for a diagnosis. Demanding neuropsych testing would be akin to relying more on an MRI than on a clinical assessment for a headache diagno...
For pediatric patients who are being successfully treated for migraines with a TCA such as amitriptyline, would you consider starting an additional SSRI or SNRI for mood/anxiety symptoms, given the risk of serotonin syndrome?
My first inclination would be to just increase the TCA that is already being used and bring it up to therapeutic levels for antidepressant and anxiolytic effects. The TCAs are very effective antidepressants but come with a wider array of side effects, which makes compliance a bigger issue with these...
How do you manage a patient with severe mental illness whose psychiatric symptoms worsen significantly during inpatient cancer treatment?
There are many issues to keep in mind, such as not all "mental illness" is necessarily a primary psychiatric disorder. Below are some common problems: For management of steroid-induced psychosis/mania, which typically has an onset within 3–4 days with risk >80 mg/day prednisolone equivalent. I would...
How do you approach the use of SSRIs to treat bipolar depression?
I don't consider antidepressants first-line treatment for my patients with bipolar disorder. I have all my bipolar patients on a mood stabilizer, usually lithium or lamotrigine. I also tend to add an antipsychotic to the mood stabilization regimen for the majority of my patients, usually generic for...