Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to duration, dosing, and continuation of lithium monotherapy in patients with a single lifetime manic episode stabilized on lithium?
There are a number of variables involved here in making this decision. It only takes one manic episode in a lifetime to make the diagnosis of bipolar one. However, when deciding the duration of lithium, I would like to know what the rest of the patient’s mood trajectory has been. Are they pretty muc...
For breakthrough psychosis on a maximized LAI, do you add oral supplementation or shorten the injection interval first?
It depends on the timeline of symptomatology and the LAI; if the individual has resolution of symptoms that return temporally as they get closer to their scheduled LAI, I will try to shorten the interval. If there are significant symptoms despite use of the LAI, I would augment with oral supplementa...
What is the first intervention you reach for when a caregiver shows signs of burnout?
In these situations, I often spend time understanding the situation, as each situation is unique. Once I have more information regarding the particular situation, I then problem-solve with the caregiver. Interventions may include referrals to Area Agencies on Aging for support, referral for psychoth...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
Which patients are good candidates for transcranial electrical stimulation for the treatment of chronic insomnia?
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that has demonstrated efficacy in the treatment of insomnia in randomized clinical trials, although evidence supporting its long-term effectiveness remains limited. Studies have reported improvements in both subjectiv...
What is your preferred PRN for management of pediatric agitation in the emergency department?
Choice of drugs depends on specific clinical presentation, psychotropic medication history, and comorbid medical conditions. Many, perhaps most, children's hospitals have electronic order sets for agitation in urgent settings, with allowances for override as these specific variables dictate. My typi...
How do you navigate C-2 refills in patients who are stable in their treatment and do not otherwise need to be clinically seen monthly?
This practice is routine in child psychiatry. We fill stimulant prescriptions electronically at the phone request of the family as long as they are keeping quarterly appointments. We do not charge for that service. We do document it in the medical record. Your question begs another question, however...
How would you decide between escalation to clozapine vs xanomeline-tropsium (Cobenfy) for treatment-resistant schizophrenia?
Clozapine is the only agent FDA approved for treatment-resistant schizophrenia (TRS) as well as suicidality associated with schizophrenia or schizoaffective disorder. Clozapine has also robust anti-hostility and anti-aggressive effects as established in double-blind randomized clinical trials, inclu...
Have you found aripiprazole effective for treatment of psychosis and bipolar mania in practice?
While aripiprazole is approved for schizophrenia, I rarely use it for treating this condition. I do not find that it is effective enough to treat true psychotic symptoms when compared to almost all other SGAs. The same goes for bipolar mania. Instead, I tend to use aripiprazole for less severe cases...
How would you treat psychotic symptoms in a patient with atypical psychotic-induced leukopenia with absolute neutrophil count (ANC) below 500 cells/µL (<0.5 x 10^9 L)?
I have not been faced with that situation except on Clozaril. I will use benzodiazepines initially to control anxiety and reduce the stress with psychotic symptoms. Later, when the white count starts to improve, I will initiate a different drug. Will go slow and check counts often enough not to miss...