Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients with depression about the role exercise may play in alleviating depressive symptoms?
I’m a big fan of exercise for all of my patients, to the point where I have my 5th-degree black belt diploma on the wall of my office next to my undergrad, PhD, and MD diplomas. I tell patients, “That’s up there to say to try and fit in exercise as realistically as your schedule allows, in a way you...
How do you counsel patients who want to understand why sublingual cyclobenzaprine works to relieve their fibromyalgia pain and other related symptoms?
I like to set the stage with patients and make sure they clearly understand the link between sleep disruption and pain sensitivity, particularly in the context of central pain and fibromyalgia. One of my rheumatology attendings during fellowship used to explain this using classic sleep research from...
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...
How do you treat disruptive mood dysregulation disorder?
DMDD is quite an enigma. The whole concept of irritability, which transcends many diagnoses, is also interesting. DMDD was meant to avoid overdiagnosis of moody disruptive behavior as bipolar. Since many of those kids are not suffering from bipolar disorder, I thought it was a great move. Unfortunat...
What doses of lithium have you found effective in reducing suicidal ideation?
For depression augmentation in patients who have non-bipolar states, I generally use 150-450 mg (low-dose lithium). The blood levels usually range below therapeutic for bipolar, but the low-dose lithium can help reduce SI without too many side effects. I still watch for issues of thyroid and kidney ...
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...
How do you view the risk of tardive dysinesia and other side effects in your female patients with treatment-resistant depression who are stable on an atypical antipsychotic?
Superb question, and it also applies to bipolar disorder, which is even more challenging in this patient population. I like Dr. @Dr. First Last's answer, always a risk/benefit analysis. Probably what you are already doing is my guess, since you are asking this question. Make sure you are doing consi...
When do you consider the use of lumateperone to treat schizophrenia spectrum disorders?
It is obscene that these drugs cost $1,400-$1,800/month retail.
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
How do you approach disposition planning when a patient makes homicidal threats on presentation to the emergency department but later recants?
We are psychiatrists, and we have our area of expertise... the legal system has theirs... the legal system, NOT the medical system, has created Tarasoff or more specifically THE DUTY TO WARN. I have taught residents, medical students, and nurse practitioners for many years, and I present a very simp...