Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
How do you approach diagnosing suspected early tardive dyskinesia with minimal positive findings on AIMS examination?
Before adding any medications, I generally try to remove any offending medications, like antipsychotics, or meds like stimulants that can lead to tardive tics. One can see TD with SSRI medications, but it is rare. If I suspect TD despite not having a positive AIMS test, I will sometimes have patient...
How do you approach initiating esketamine treatment in older adults with difficult-to-treat depression?
Definitely a tougher crowd to treat, in general, whichever treatment is chosen. All the aforementioned considerations come into play, but it is also important to note that esketamine works well in older patients and should be offered as a treatment if it is appropriate. Regarding preliminary conside...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
How do you manage problematic disinhibited behaviors in patients with neurocognitive disorders?
This requires a problem-centered approach. I suggest the following thought process. Analyse the root cause: Is it disinhibition? Unmet needs? Under/Overstimulating environment? Medication side effect? For disinhibition (frontal lobe dysfunction): I have had success with gabapentin and low-dose Depa...
How do you treat decreased libido from SSRIs?
Serotonin-1 agonism will revert it in about 60% of cases. You have a choice of adding buspirone at about 30 mg bid or going to vilazodone which has already an SR1 agonism. Some bupropion, not clearly understood at about 300 mg can also do it. Or if possible, use vilazodone, bupropion, or mirtazapine...
What medications do you recommend for a patient with ADHD and anxiety who becomes more anxious on a stimulant?
Consider non-stimulant ADHD medications such as atomoxetine and viloxazine. Although these are not as effective for nearly as many patients as the stimulants, they are a reasonable alternative and generally well tolerated. Despite the potential for bupropion to also cause a patient to feel more anx...