Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
When do patients presenting with self harm but no suicidal ideation in an outpatient setting require a higher level of care?
This will be highly specific to the individual patient, and like all treatment decisions, hinges on a comprehensive evaluation of risks vs. benefits. Considerations include the underlying psychiatric diagnoses, the degree of self harm (severity, timing, etc.), participation in/response to treatment ...
In children with unknown family cardiac history, do you require a routine EKG prior to starting a stimulant?
The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) have stated that ADHD medications have not been shown to cause heart conditions or sudden cardiac death, although stimulant medications do increase heart rate and blood pressure. By increasing sympathetic nervous syste...
When, if ever, do you consider using dronabinol to treat agitation in dementia?
Dronabinol should be considered for treating agitation in dementia when non-pharmacological interventions and standard pharmacological options, such as antidepressants or antipsychotics, have failed or are poorly tolerated. I have a handful of patients in my practice who fit that scenario and benefi...
What are the most effective strategies for managing weight gain associated with antipsychotic medications?
In my experience, the following things have worked. Reassurance that it is a medication side-effect. Consider switching the anti-psychotic (or at least try and decrease the dose of the antipsychotic). Aripiprazole, Caplyta (Lumateperone), and Vraylar (Cariprazine) have shown benefits vis a vis weig...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
How do you differentiate major depressive disorder from baseline functioning in patients with intellectual disabilities?
A general assumption of psychiatry is that people with intellectual disabilities can be afflicted with nearly any of the psychiatric disorders apparent in the general population. However, making the diagnosis of other psychiatric disorders in people with varying degrees of intellectual disability an...
How do you determine the appropriate level of care for an adolescent with a substance use disorder?
This is a very timely question, as the use of substances in childhood and adolescence is an often-overlooked issue. A recent survey of high schoolers revealed that 11% of 8th graders, 21.5% of 10th graders, and 32.6% of 12th graders have engaged in substance use in the past month. (Miech et al, NIDA...
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 ...
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...