Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What adjustments do you make for patients with ADHD who report their long-acting stimulant wears off too quickly?
There are essentially 3 options: 1) administer the medication later in the morning; 2) add a short-acting booster dose; 3) switch to a similar formulation with a longer duration of action. I typically discuss these options with patients/families and make individualized decisions depending on the par...
What opportunities do you see for combining xanomeline-tropsium (Cobenfy) with other anti-psychotic agents?
The opportunities of combining Cobenfy with any of our other antipsychotic treatments, in my opinion, are unlimited. This is one of the most important aspects of its drug use that has NOT been systematically tested. One might think first of combining Cobenfy with a widely used drug, like risperidone...
What are your experiences with lithium target levels in the maintenance of bipolar 2 disorder?
I prefer maintenance lithium levels at the 0.7-0.8 range, because I wish to provide a more rigorous test of lithium's ability to prevent recurrence in each BPII patient.
How do you counsel patients on lithium about NSAID use?
I recommend not using NSAIDs altogether, since there are so many variables to consider if the patient is to remain safe. The patient needs to be highly aware and knowledgeable about their medications, medical problems, age, baseline labs, etc. There are not very many patients like that.
What has your experience been counseling on and prescribing Cobenfy?
I have good results from it - but just like with any medication in psychiatry, there isn't "one size fits all". There is data that shows a more rapid titration to the highest dose (125-30) works the best. It goes 2 days with 50-20, then 5 days with 100-20, then transitions to 125-30. You have to mak...
When do you consider writing an Emotional Support Animal (ESA) letter for patients with psychiatric illness?
After much soul searching, I decided that I cannot write these letters. The hard part for me is that I'm an animal lover and a pet owner, and I really do appreciate the happiness and comfort that a good animal companion can provide. But the letters are complicated, because for FHA benefits, you are ...
What pharmacologic and non-pharmacologic strategies have you found helpful in managing brain fog following COVID-19 infection?
In general, a systematic approach should be taken to evaluate COVID-19-related brain fog, which can then guide treatment. Additionally, brain fog following COVID infection can often be multifactorial, and the treatment accordingly often needs to be multi-pronged and comprehensive. The recommendation...
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...
When do you consider pharmacogenetic testing to assist in the selection of antipsychotic medications?
I don't usually consider it, as the evidence of clinical use isn't warranted unless the patient is on heroic dosing or has side effects to every medication. I usually will get plasma levels, and you can get plasma levels for pretty much any antipsychotic - it's a cheaper GeneSight. For example, if I...