Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
It is widely accepted that if liver enzymes are 3x above the normal limit, it is not advised to start naltrexone. Between 1-3x the upper limit, one has to do a pro and con analysis of whether the benefits of alcohol cessation would outweigh potential liver toxicity from naltrexone. Further, naltrexo...
When, if ever, do you consider prescribing clozapine after only one unsuccessful antipsychotic trial in schizophrenia?
I recommend clozapine only after two adequate trials of antipsychotics, at least 6 weeks in duration, with 2 weeks at the maximum FDA-approved dose, with at least one blood level during the final two weeks as a check on compliance. I try to obtain these data because clozapine has such deleterious me...
What strategies have you found effective for obtaining insurance approval for xanomeline-tropsium (Cobenfy)?
Contacting the company and talk with their representatives and they can help facilitate the process, i.e. , resources to connect the patient with and/or samples until they can get it in a financially responsible manner
Which patients do you think would benefit most from xanomeline-tropsium (Cobenfy) monotherapy?
What we know best about this new drug, Cobenfy, a xanomeline-trospium combination, is that it does not directly affect the dopamine receptor, so it is novel and a new antipsychotic drug. And its antipsychotic efficacy has been demonstrated and accepted by the FDA. But still, we have a rather ‘pure’ ...
What has your experience been with using SSRIs to treat negative symptoms of schizophrenia?
Thirty years ago, I tried various SSRIs for negative symptoms, with no improvement according to the patient and caregivers.
How do you identify and respond to possible elder abuse in patients with dementia?
Elder abuse, also known as elder mistreatment, includes psychological, physical, and sexual abuse; neglect, which includes caregiver neglect or self-neglect, and financial exploitation. Physical abuse includes the infliction of physical pain or injury to an older adult, which may result in bruises, ...
Which cardiac comorbidities prompt you to obtain cardiology evaluation before starting stimulant treatment in adults with newly diagnosed ADHD?
Cardiac conduction abnormalities are a concern, as the heart will be working harder with a stimulant on board, which can worsen conduction abnormalities. Also, anyone with cardiomyopathy has to be treated carefully, as the cardiac muscle has to work harder with stimulants on board. In both cases, pa...
Is there sufficient evidence yet to support the use of lithium supplementation or prescription in the management of neurodegenerative diseases?
No.I assume the question was written in response to a recent publication in Nature (Lithium deficiency and the onset of Alzheimer’s disease), highlighting recent research in mouse models where lithium deficiency in the brain led to accelerated amyloid pathology, which could be in part reversed by re...
How do you manage patients with bipolar I disorder who report emotional blunting or numbness while taking lithium?
Adjusting the once-daily bedtime dose to a lower level in the therapeutic range may help. I always tell patients that this is a recognized side effect of lithium. A discussion about the often unavoidable depressive episode following a manic episode may convince patients that avoiding a manic or hypo...
When do you check vitamin D levels in patients with depressive symptoms?
I routinely check 25-OH D in all my patients. Given that half the population is deficient and that we now know the role of vitamin D not only for bones but in mood, cognition, and immunity. We need to be aware of deficiencies and replete if low. Moreover, ideal levels are 60-80, not just over 29 as ...