Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you approach the use of benzodiazepines in patients with chronic medical illnesses that may be susceptible to respiratory compromise (e.g., CHF, COPD, ILD)?
It’s a very good question and answers may vary among different specialty providers. Yes, a slow or gradual weaning of the benzodiazepines would be advisable. When they reach lower doses the taper should be even slower over weeks or longer. There is a risk for not weaning them off benzodiazepines inc...
What considerations do you take regarding using valproic acid in men who are hoping to conceive with a partner?
This recommendation was based on an analysis of one retrospective study, with data being re-analyzed, in addition to case reports and animal studies. It seems to me that it's too soon to be making rash decisions about treatment, but informing patients of the possibility and uncertainty seems reasona...
How do you manage emotional blunting due to SSRIs/SNRIs?
As with other classes of psychotropic medication, I have found that even though two medications may be in the same class, a particular patient may experience different responses to them, both in effectiveness and/or side effects. So, if that occurs, I will often try another medication in the same cl...
What is your next step in management for patients who develop sexual side effects on an SSRI (anorgasmia, low libido, etc.) but are responding well to therapy?
Managing side effects from SSRI medications is a key component of treating patients in the outpatient setting who are suffering from depression and/or anxiety. This is doubly true given the fact that primary care is often the most accessible, and often most trusted, source for patients to make their...
How do you assess and adjust treatment in patients who develops hypothyroidism after being on lithium for several years?
It depends on whether the patient is symptomatic. If not, careful monitoring is all that is needed. If there are significant symptoms, treatment with levothyroxine would be needed. Continued use of lithium is appropriate if it has been effective over time.
How do you approach the use of SSRIs to treat bipolar depression?
I don't consider antidepressants first-line treatment for my patients with bipolar disorder. I have all my bipolar patients on a mood stabilizer, usually lithium or lamotrigine. I also tend to add an antipsychotic to the mood stabilization regimen for the majority of my patients, usually generic for...
When do you consider lithium for early intervention in those identified to be at risk for bipolar disorder?
Lithium is the preferred first-line agent for bipolar disorder. It offers patients the potential for as close to a cure (restituo ad integrum) as you can get in psychiatry. For this case, I would initiate a 150 mg dose, and potentially build to a low-moderate dose (300-450 qhs) and watch and wait ov...
Other than clozapine, what antipsychotics do you use in a manic or psychotic patient with TD?
Lumateperone is quite all right with minimal D2 involvement. But don't forget the blocking of VMT.
How do you counsel patients who are interested in dietary approaches for managing major depressive disorder?
In integrative medicine literature, there is some evidence that following an anti-inflammatory diet can improve mood symptoms, including MDD. I imagine this would be a good place to start, and certainly, keto diets are considerably less inflammatory than sugar-based diets with high levels of simple ...
When is the best time to get a valproate level if a patient is taking Depakote DR once daily?
Levels should be obtained at steady state - which is 5 half lives. For ER formulation, figure about 5 days and it should be a trough level (immediately before the next dose).