Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Do you recommend GLP-1s for antispychotic induced weight gain?
When antipsychotic induced weight gain causes obesity (BMI>30), I recommend a trial of tirzepatide or semaglutide. I have observed the typical benefits in my patients, including decreases in lipids, lower HgbA1c, lower BPs, improved mobility, and loss of 10-20% of body weight over 6 months. Expense ...
Would you consider starting a stimulant in an inpatient or crisis setting for patients whose severe behavioral issues are due to untreated ADHD?
For an adult without an established diagnosis, I don't believe initiating stimulant therapy during an acute inpatient stay is appropriate. ADHD is a legitimate neurodevelopmental condition, but it shouldn't be used as a catch-all explanation for behavioral disruptions in a hospital setting. Starting...
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
How do you manage ARFID in children encountered in your practice?
ARFID is a fairly new disorder, having been added to the DSM in 2013. Treatment somewhat depends on the type of ARFID with which the patient presents, although there are shared treatment elements regardless of type. Variants include Avoidant type, which usually revolves around sensory issues related...
How do you use lithium levels to adjust treatment during mania?
If someone is getting manic, the mania in itself reduces lithium levels. You need for a period of about 6 weeks maintain a level close to 1 in contrast to a maintenance level of 0.75. I would, of course, use the appropriate antipsychotic to help during this period. If the patient has been Li respons...
What role do you think AI-based clinical decision-making aids should play in psychiatric practice today?
Not yet. AI is still in its infancy and may be prone to "hallucinating" answers, as indicated by the legal cases where AI simply manufactured case precedents that don't exist. This is a risk that is probably not necessary in psychiatric diagnosis and treatment at this point in history. Although usin...
What strategy do you find most effective for outpatient induction of buprenorphine in opioid use disorder?
The method for induction of Buprenorphine for OUD needs to be tailored for the specific patient and the environment. The standard induction was introduced during the time when heroin was the most common opioid being used on the streets, as well as diverted prescription narcotics. Also it was mainly ...
How do you approach treatment of obsessive behavior in patients with autism spectrum disorder?
This is such a rich topic, which comes up frequently in my practice, and the diagnostic distinction has real treatment implications. I think it’s helpful to start with some definitions, in which the key is function, not topography. OCD obsessions/compulsions: ego-dystonic, anxiety-driven, patient r...
When, if ever, do you consider prescribing clozapine after only one unsuccessful antipsychotic trial in schizophrenia?
I have read a recent JAMA Psychiatry paper concerning clozapine initiation after 1 antipsychotic trial, which was not successful (Li et al., PMID 41811299). I have not changed my practice, which is to require 2 such trials (which blood level confirmation to eliminate non-compliance) before prescribi...
How do you weigh the risks of antipsychotic induced metabolic side effects when treating behavioral symptoms of dementia in a patient with diabetes?
This is an excellent question and is a difficult clinical metabolic risk concern in a poorly characterized population. Most of what we know about antipsychotic-induced metabolic syndrome, such as weight gain, dyslipidemia, insulin resistance, and hyperglycemia, comes from younger patients with schiz...