Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage cannabinoids (ex: medicinal, recreational) in dermatology?
I use dronabinol 2.5-10 mg qd-tid for recalcitrant pruritus (typically neuropathic or CPUO as an adjunct treatment). Very cheap using GoodRx if not covered by insurance. It’s a scheduled drug, so it requires DEA, but you don’t need a “medical marijuana license,” and it’s very well tolerated outside ...
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...
When, if ever, do you consider increasing Adderall above the FDA-approved maximum daily dose of 40 mg for adult patients?
I titrate the dose based on the patient's needs, functioning, and tolerances.
When do you consider adding an antipsychotic for SSRI-refractory OCD, and which agent do you typically choose first?
There are so many factors that play into my decision-making; it truly is a case-by-case basis. In my opinion, the most common mistake is not adequately titrating the dose of the SSRI. You also need to make sure they are getting high-quality CBT/ERP at least 1x/week, ideally 2x/week for the first mon...
What is your approach to managing sexually inappropriate behaviors in hospitalized patients with psychotic symptoms?
Sexually inappropriate behaviors, commonly abbreviated as ISB in the behavioral and sex offender treatment communities are very often problematic, especially when combined with psychosis. ISB can vary from relatively mild, such as accidental self-exposure by a confused patient, to the very severe, s...
How do you approach patients with fibromyalgia who are reluctant to consider a psychiatric component to their illness but present with clear mood or anxiety symptoms?
Since patients with fibromyalgia (FM) are often stigmatized and worried that clinicians think “it is all in my head,” it is important to discuss FM treatment and mental health referral from a biopsychosocial perspective. This might include introducing concepts such as the pain/depression dyad, centr...
When do you refer patients with difficult-to-treat depression for consideration of TMS or esketamine?
We typically tend to refer patients with Treatment-resistant depression (TRD), which is defined as failure to respond to two or more adequate trials of antidepressant medications. An adequate trial is determined by both dose and duration and generally requires at least 4 weeks of treatment at a dose...
When do you recommend HLA testing prior to prescribing lamotrigine, carbamazepine, or oxcarbazepine to patients of Asian descent?
I never use carbamazepine, given how it’s a pan-inducer and often lowers the level of other medications that may be in the regimen, such as quetiapine and haloperidol, since they are mainly metabolized by CYP3A4.Oxcarbazepine has a 50% reduction in the induction of carbamazepine, so I use that somet...
How do you approach continuation of benzodiazepines in elderly patients with anxiety who have had poor response to other medications?
This is a risk/benefit analysis question, and will be unique for each patient. The biggest danger is making an internal rule that ignores the patient's needs. Many variables come into play: if the person has been on them for years or decades, then it probably causes more harm to discontinue, as they...
What is the role of cognitive training exercises in older patients with short-term memory problems and/or are diagnosed with mild cognitive impairment?
You are correct. The evidence so far is level C - as far as I know. No robust RCTs. Exercise gets a Level B recommendation. You may maximize benefit by offering more supervision (supervised computerized cognitive training), combining with resistance training, and/or increasing frequency. Most effect...