Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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?
Tarasoff rules. Tarasoff v. Regents of the University of California The ER department remains in the purview of all medicine in the USA, in my opinion. “How do you approach” is the same regardless of the setting. The thought of the clinician remains superordinate. Is this really a question? Recant.....
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...
How do you approach patients who present repeatedly to the ED with suicidal ideation but no clear acute change in risk?
If a young patient presents repeatedly to the ED with SI, even if there is no change in acute risk, it is an indication that whatever is being put in place is not working well enough to support the patient, and/or a communication of the young patient's distress. This warrants a careful assessment of...
When do you consider using benzodiazepines to treat insomnia in patients with acute mania?
In acute mania in younger patients, benzodiazepines can be a very helpful adjunct to mood stabilizers when they are not able to control the hyperactivity and insomnia with mood stabilizers alone. In younger patients, I will go with longer-acting benzodiazepines, and in shorter-acting ones for older ...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
How would you decide between escalation to clozapine vs xanomeline-tropsium (Cobenfy) for treatment-resistant schizophrenia?
Clozapine is the only agent FDA approved for treatment-resistant schizophrenia (TRS) as well as suicidality associated with schizophrenia or schizoaffective disorder. Clozapine has also robust anti-hostility and anti-aggressive effects as established in double-blind randomized clinical trials, inclu...