Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you discuss lithium with patients who are hesitant due to concerns about side effects or monitoring requirements?
I inform patients that lithium is one of the oldest and most studied mood stabilizers. Many people do well on it for years with no or minimal side effects. Patients report that after years of suffering, it provides a sense of calm and helps with sleep. There is some evidence that it reduces suicide ...
How do you transition severely agitated ICU patients off a dexmedetomidine infusion when it is being used primarily for psychiatric agitation?
Even if initial agitation is felt to be psychiatric, it is important to remember (and remind involved teams) that following intubation and sedation in the ICU, rebound agitation as dexmedetomidine is weaned may have become multifactorial. As such, interventions such as monitoring for contribution fr...
When do you consider starting an antidepressant without a mood stabilizer in a patient with a historical diagnosis of bipolar II disorder who has not had hypomanic episodes in many years?
I happen to have a patient just like this now on my inpatient service. One of the problems we run into often is uncertainty around the validity of the bipolar spectrum in the first place. We see so much complicated trauma, maladaptive behaviors, and disordered personality structures that periods of ...
How do you approach antidepressant selection in patients with prolonged QTc?
In 2018, the American Psychiatric Association published a resource document on "QTc Prolongation and Psychotropic Medications," which was later followed up by a 2020 American Journal of Psychiatry publication: These manuscripts highlighted a few key points when making clinical decisions related to Q...
How do you treat extrapyramidal symptoms secondary to anti-psychotic use in patients who have not benefited from cogentin or benadryl?
In general, when addressing motor symptoms from antipsychotics (or any dopamine-blocking agents including dopamine-blocking antiemetics), I find it useful to break things down more specifically than just EPS. This often will determine the agent that will be most beneficial. First Category: Hypokinet...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
How do you approach stimulant prescribing for ADHD when a patient has previously reported palpitations with stimulants but has a normal EKG off medication?
Get a cardiology consult and get a certificate about stimulant safety before initiating stimulants.
How do you manage withdrawal symptoms after stimulant discontinuation?
I have not witnessed bradycardia as a withdrawal symptom of stimulants at therapeutic dosages, although this is common with misuse/SUD. I have noticed increased behavioral and mood symptoms due to stimulant discontinuation, which may be related to shortages. I simply use whatever formulation is avai...
When do you use extended-release buprenorphine instead of daily formulations?
Extended-release buprenorphine (e.g., Sublocade, Brixadi) can be a good option for patients who have trouble staying stable on daily sublingual doses, especially those with adherence challenges, ongoing exposure to high-risk opioids such as fentanyl, or concerns about safety and diversion. Weimer et...
How do you evaluate and manage patients who report vivid, distressing dreams or “epic dreaming” that disrupt sleep quality?
Nicotine or nicotine replacement being used? (Very common cause) Varenicline (Chantix) for smoking cessation being used? (Known effect) Melatonin being used? (Possible, more likely with high/excessive doses) Recent reduction or cessation of an antidepressant resulting in REM rebound? (Known to cause...