Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage polyuria and polydipsia from lithium?
My first step is to confirm that the symptoms, including polydipsia and polyuria, are due to NDI and not other reasons. Other potential causes that should be excluded are: Psychogenic polydipsia other substance-induced, such as caffeine, diuretics primary DM pituitary related CKD Lowering the dose...
What medications do you find helpful to reduce drooling associated with antipsychotics?
Atropine Ophthalmic Solution 1%: 1 GTT SL QHS. The two leading theories explaining the mechanism of sialorrhea are: Potent agonism at muscarinic M4 receptors. Blockade of alpha-2 adrenergic receptors. Both mechanisms increase salivary flow. Atropine Ophthalmic Solution is absorbed locally. It shou...
How do you approach psychopharmacologic treatment of ADHD in correctional settings?
Correctional settings are very specialized in terms of psychopharmacological prescribing. The nature of the criminal or adjudicated actions the patients may have committed, the need for patient and staff safety, the desire not to inadvertently provide medications that could be used to commit a crime...
What factors influence your decision to continue or taper antipsychotics for behavioral symptoms of dementia after the acute phase resolves?
With no FDA-recommended treatments for severe behavioral symptoms of dementia, the most recent American Psychiatric Association (APA) practice guidelines of 2016 continue to recommend antipsychotic drugs when medical and environmental factors have been tended to (Reuss et al., PMID 27133416). While ...
How do you counsel/approach antidepressant use in patients planning to utilize or self-administer psychedelics for chronic PTSD or depression?
I think this is a really relevant question with the rise in psychedelic use. I was working in Denver, CO, and a LOT of my patients admitted to using mushrooms or were seeking ketamine treatment. And all of them were looking into the research; sometimes being more up-to-date than even myself. With ke...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
How do you manage daytime somnolence without a clear cause?
Throw a broad net out for the evaluation because we don't know how much has a physiological component and how much is mental/emotional. At intake, I get a moderately comprehensive set of labs. Rating Scales like HAMA, HAM-D, PHQ-9, Epworth Sleepiness Scale, and a ROS (Review of Systems) are done. I...
What pharmacologic therapy, if any, do you recommend for treatment of borderline personality disorder?
Given the mood instability in patients with bipolar disorder, I thought it would be a rational option to a trial of a mood stabilizer. I explained my thinking and each agreed. So far, with a very small number of patients, the results have been excellent. I start with a small dose, and slowly and gra...
How have you gone about implementing TMS in your practice or institution?
For me, the hardest issues with TMS are getting insurance to approve it and the time it takes from a patient’s perspective to see a benefit.When I first invested in the TMS machine, I calculated it could take up to 3 years to pay off the equipment cost. In actuality, I was able to recoup the initial...
What is your experience with transcutaneous vagal nerve stimulation for the treatment of anxiety disorders and major depressive disorder?
Just starting to recommend, have had a few folks with side effects and unclear results. A colleague noted about a 30-40% response rate.