Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What are your preferred methods for QTc calculation for normal, tachycardic and bradycardic heart rates?
This depends on the need for precision. If for clinical purposes, the Fredericia correction formula will suffice and is less sensitive to heart rate distortion than Bazett's. If the goal is to precisely define the QT interval in a clinical trial, such as a thorough QT study of a new chemical entity,...
How do you schedule follow-up visits for pregnant patients with a history of depression, both during pregnancy and in the postpartum period?
The frequency of visits is not, or not simply related to diagnosis, though the presence of a very severe depression or any bipolar episode would require more frequent visits than a history of depression alone. It would be important to know from a thorough longitudinal history what the patient's depr...
How do you manage obsessive-compulsive symptoms secondary to clozapine?
You have to find a good balance, which can be very challenging if the psychosis and OCD are prominent. Clozapine exacerbates OCD the most out of any antipsychotic. You can use Luvox to help boost clozapine levels and decrease norclozapine levels, which is the main culprit of metabolic side effects; ...
How do you counsel patients on the risks and benefits of antidepressant use during pregnancy?
I always frame the decision as being between the risks and benefits of the medication vs. the underlying condition. We are always aiming for the "minimum effective dose" but "effective" is just as important as "minimum." Medications are, of course, not the only way to treat psychiatric illness and a...
What adjunctive therapies to you recommend for symptom control in acute opioid withdrawal beyond full/partial opioid agonists?
Here are some general recommendations below. I recommend asking the patient what symptoms are most bothersome or what they anticipate to be the most bothersome when prescribing adjuncts. I routinely recommend APAP/ibuprofen, and then usually prescribe something for anxiety and nausea. Tizanidine can...
How do you approach the evaluation and treatment of insomnia in children?
The evaluation and treatment of insomnia in children requires a structured assessment of sleep patterns, contributing medical or behavioral factors, and the implementation of primarily behavioral interventions, with selective use of pharmacologic treatments. Identify Sleep Complaint: Difficulty fall...
What is your response when a high functioning adolescent with mild ASD features asks for an autism diagnosis?
The response to any child asking for any diagnosis is to explore the reason for the request. Why do they “want” it? What do they imagine would change were they to get the diagnosis? There are many possibilities. Is it to lessen their own shame about their struggles, as ASD is now a more “acceptable”...
Given the mixed evidence for N-acetylcysteine in adolescent cannabis use disorder, how do you approach discussing this with families?
A thoughtful addition to the discussion on NAC in adolescents with cannabis use disorder is to emphasize how and when it is used. In many young patients, cannabis use is not simply recreational or oppositional, but a compulsive attempt to manage obsessional anxiety. When this pattern is recognized—p...
What strategies do you find helpful to stop zolpidem in patients who have been taking the medicine for months or years?
Zolpidem has significant withdrawal, and if not careful, the patient will perceive it as a need for zolpidem for sleep. Technically, it is not working after about 6-8 months due to the accommodation of receptors. Please use lemborexant hintly for 1 week, reduce to 2.5 mg zolpidem for 1 month, and th...
What is your approach to Tardive Dyskinesia when VMAT2 inhibitors are ineffective or unaffordable?
In established cases of tardive dyskinesia, in which withdrawal-emergent dyskinesia has been ruled out, and dyskinesia has persisted despite a sufficient washout interval after removal of the offending agent, VAM2 inhibitors such as valbenazine and deutetrabenazine are used for pharmacotherapy. If t...