Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
When do you consider using dual orexin receptor antagonists (DORAs) for the treatment of insomnia?
I only consider using any hypnotic in insomnia when the patient is getting only 5 hours or less of sleep. In those cases, I will sometimes try using DORAs. I am a sleep neurologist who sees patients with MCI/early dementia, and I have found these medications useful in this population of patients wit...
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...
Do you consider using buspirone for the management of anxiety in older patients?
While buspirone has been FDA-approved for the treatment of generalized anxiety disorder (GAD) and for short-term relief of anxiety symptoms in general since the 1970s, it is not generally considered a first-line treatment, despite its low misuse potential as a non-benzodiazepine. There are no large ...
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...