Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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 ...
In a woman with bipolar disorder with a menstrual component would lamotrigine itself worsen the condition given that it interacts with prescribed estrogen?
Very unlikely. Estrogen can cause a lowering of the Lamictal serum levels and not vice versa. So, if a patient on Lamictal is put on an estrogen product, there may be a need to increase the dose of Lamictal.
What parameters do you follow to avoid rebound effects when using clonidine only for nightly or daily as-needed indications?
I use a fair amount of clonidine in my practice, and I haven't found any rebound blood pressure effects for people who take clonidine nightly or for PRN use. In fact, I've stopped routine practice of checking blood pressure for those who are not taking a standing daily dose. I worry about rebound mo...
How do you approach managing clozapine in patients who are critically ill?
With COVID-19 disproportionately affecting those with mental illness we found an increasing number of medical admissions for those on clozapine. There are multiple domains of concern for those on clozapine who are medically ill. Clozapine levels have been shown to potentially double during periods o...
How do you weigh risks/benefits when referring child and adolescent patients for ECT?
I want to begin with a disclosure: I do not personally treat children with ECT in my practice. However, in a prior academic setting where ECT was performed for adults, I was occasionally asked to evaluate adolescents being considered for treatment by the adult ECT service. When thinking about referr...
When do you start pharmacotherapy for PTSD in children?
The only medications to be used are to address sleep disturbance and nightmares. Poor sleep has been shown to increase PTSS. So prazosin and, on occasion, clonidine should be used. And they should be used as early as possible. SSRIs are generally not that effective and should only be considered if t...
What is the role of inpatient psychiatric or psychological evaluation in patients who have had acute function change as an inpatient?
This is an important question. An acute change in function is a frequent reason for hospital admission and must be considered as a feature of some underlying medical, neurological, or psychiatric condition. It is important to know what functions have changed, including basic and instrumental activit...
How do you approach treatment-refractory schizophrenia which has not responded to multiple antipsychotic trials including clozapine?
I would also add that there are now case reports and case series of the ketogenic diet having significant benefits for the treatment of refractory schizophrenia, including some cases of those who had not benefitted from clozapine. The mechanisms of action by which a ketogenic diet improves brain hea...
What varying approaches do you take in suicide risk assessments?
I agree with the following from Dr. @Dr. First Last: "Ultimately, no scale or method is going to be perfect. We are unfortunately bad at predicting which individuals with suicidal ideation progress to an attempt. The most we can do is gather as much information as possible about how someone is feeli...
How do you manage nausea side effects in patients on cariprazine?
Have them try taking it every other day. This can offset side effects, given the long half-life.