Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Do you find that hydroxyzine worsens cognitive symptoms in patients who are already susceptible to cognitive impairment?
Hydroxyzine should not have a direct negative effect on cognition. For decades after its inception, it was lopped in with Benadryl in terms of its receptor binding affinity profile and is listed in several anticholinergic burden scales as being anticholinergic. Similar to the child’s game ‘telephone...
What medication management strategies exist for children with neurodevelopmental disorders who respond poorly to stimulants and have intolerable side effects on antipsychotics?
Although neurodevelopmental disorders include ASD, ADHD, communication disorders, intellectual developmental disorders, tic disorders, and motor disorders, I will focus on ASD and ADHD, based on the question. And although the various stimulants and antipsychotic medications have different side effec...
What medications best treat Intermittent Explosive Disorder?
Anecdotally (based on my experiences only), anything and nothing. It appears to be an intellectual/cognitive issue and most often a symptom of a wider pathology e.g., a history of trauma. Pharmacological treatments therefore seem only partially effective at best. With PTSD as the most common parent ...
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...
How do you manage acting-out behaviors in children in short-term crisis settings?
Managing behavior is a complex concept and difficult to address in a generic way. In general, it's helpful to conceptualize behaviors using the ABCs of a behavioral analysis. First, what is the antecedent to the behavior? This may take different forms depending on the environment. A general emergenc...
What policies do you take regarding legalized recreational marijuana or medical marijuana use in transplant patients?
The use of THC and CBD is becoming an increasingly important topic in solid organ transplantation. Recent survey data has demonstrated that daily cannabis use is higher than daily alcohol use in the U.S. (Caulkins, PMID 38775461).Certainly, the legalization of THC use in many states has led to consi...
When do you select cholinesterase inhibitors vs NMDA-antagonist medications in patients with moderate Alzheimer’s dementia?
Cholinesterase inhibitors should be given to all patients (unless there is a contraindication) with Alzheimer's dementia since this class slows cognitive and functional decline as well as reduces all-cause mortality. Memantine, an NMDA receptor antagonist, is only FDA-approved for moderate to severe...
When do you consider using phenobarbital over symptom-driven alcohol withdrawal protocols for patients at low-to-moderate risk of withdrawal complications?
While traditional frameworks often reference "low" or "moderate" risk for alcohol withdrawal complications, in clinical practice we find it more useful to focus on the treatment setting and validated predictors of severe withdrawal rather than subjective risk labels. Phenobarbital is increasingly us...
How do you decide whether to start MAT for opioid use disorder during hospitalization?
There are several considerations when approaching patients about MOUD. In general, every patient should be offered MOUD during their hospitalization because every admission represents an opportunity towards substance recovery. With that said, I don’t entangle substance use treatment with their medic...
What strategies have you found helpful to manage SSRI associated night sweats?
Reduced dose to the lowest effective dose. Gabapentin can be used off-label for hyperhidrosis and vasomotor symptoms of menopause. I had one patient on an SSRI for GAD and found the gabapentin helpful enough for anxiety that he tapered off the SSRI. If it is just night sweats, you can do a nightly ...