Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach titration or transitioning to Cobenfy in patients currently on an antipsychotic?
Antipsychotics with significant anticholinergic activity, such as olanzapine and clozapine, can add to the effects of trospium contained in xanomeline-trospium combination. Product labeling reads "Concomitant use of COBENFY with other antimuscarinic drugs that produce anticholinergic adverse reactio...
What is your approach to delayed or inhibited ejaculation related to SSRI sexual dysfunction?
There are several theoretical possibilities that have been suggested over time. Periactin 4mg 30 minutes prior to sex is noted as a possible intervention. I've never seen any benefit from this. Another possibility is to add Wellbutrin at regular dose which allows for additional sympathetic nervous s...
How do you approach treatment-resistant depression and anxiety related to menopause refractory to SSRI/SNRIs and hormone replacement therapy?
First, I try bupropion and have found that the dopaminergic medication is excellent for refractory depression, especially as one ages because dopamine gradually decreases 10% per decade (Berry et al., PMID 27807030). If bupropion doesn't help, then I have used pramipexole quite effectively over the ...
What has been your experience with alternative injection sites to the abdomen for improving pain/tolerability with buprenorphine extended release?
I agree with Dr. @Dr. First Last's comments about 1) rotating injection sites on the abdomen, 2) considering alternate sites per the new package insert, and 3) pretreating with lidocaine. In addition, I would recommend considering Brixadi, which has a smaller gauge needle (23G as opposed to a thicke...
How do you counsel patients when they ask whether the SSRI or SNRI antidepressant you have recommended will result in weight gain?
This recent study on antidepressant-associated weight gain has generated a lot of interest and press, and can be a helpful starting point: Petimar et al., PMID 38950403.As with all studies, it has its limitations, but highlights that many people will experience minimal-modest weight change on antide...
When do you consider using ketamine to treat depressive symptoms in patients with borderline personality disorder?
It's understandable to exhibit caution when treating patients with borderline personality disorder (BPD) with ketamine. Naturally, questions arise as to the efficacy of the treatment and whether they may experience destabilization while under the influence of the drug. Still, there is no literature ...
What treatments have you found to be most effective in patients with a schizo-obsessive disorder?
This is a good question, as this happens in about 30% of our patients who have this. It depends on the severity of the psychosis versus OCD. Sometimes it’s hard to tease out are we're dealing with psychosis or the OCD is so severe it comes across as psychosis. That’s the first step. Then, as I said ...
When do you consider the use of an MAOI in treatment-resistant major depressive disorder?
MAOIs can be great in treatment-resistant depression, but after you explain how there might need to be some dietary restrictions, patients generally refrain from wanting to try them. To be frank, the dietary restrictions are overblown (A concise guide to monoamine oxidase inhibitors). There are 2 pa...
Do you screen for MTHFR polymorphisms in your patients with treatment-resistant depression?
In the trial by Papakostas et al., PMID 23212058, we have shown that adjunctive L-methylfolate at 15 mg/day had significantly greater efficacy compared with continued SSRI therapy plus placebo on both primary outcome measures (response rate and degree of change in depression symptom score) and two s...
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...