Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients who want to use vaping to quit smoking cigarettes?
My patient population is largely persons with severe opioid use disorder. Most use tobacco/ nicotine in some form - typically cigarettes and/or vaping. I have seen people minimize their use of cigarettes with vaping and feel very happy with their results. I don't see, however, a lot of patients stop...
What is the best approach to treatment for cenestopathies (sensation of electric current in patient's brain) accompanied by anxiety and inability to sleep?
Thank you for your question. Cenestopathies (referring to the feeling of being ill and this feeling not localized to one region of the body) may not be the correct term for this interesting phenomenon, commonly called "brain zaps". Brain zaps are a poorly understood symptom of antidepressant withdra...
When do you consider using valproate to manage behavioral disturbances in patients with delirium?
Multiple studies have identified valproate as a potential option for the management of agitation in hyperactive delirium. This has particularly been investigated for patients in ICU settings with some studies finding positive outcomes such as reduction of the total number of concomitant psychoactive...
How do you treat a patient with moderate dementia who experiences a recurrence of depression?
When I get a patient with moderate dementia and depression, I make sure the basic potential reversible medical contributors have been looked into and corrected (i.e., B12/D3 deficiency, OSA, etc). If the patient is on medications that could contribute to depression, I discuss with PCP and family if ...
In what clinical situation would you consider using benzodiazepines in patients with dementia?
When a dementia patient is in the moderately severe or severe stages of the disease and has palliative goals of care, they would be eligible for palliative care FAST 6 or hospice FAST 7. Caregivers are no longer trying to maximize independence. The patient has 24/7 supervision. The caregiver is at r...
Given some of the theoretical relationship between glutamate and OCD, do you ever consider the use of NMDA (or AMPA) antagonists for the treatment of refractory OCD?
We recently published a systematic review and meta-analysis on glutamate-modulating agents in the treatment of OCD as augmenting agents to SSRIs or as monotherapy. Overall, we found that glutamatergic medications led to significant improvement (statistically and clinically) in OCD symptoms. We also ...
What strategies have you found effective in reducing intake no-show rates among patients with severe and persistent mental illness?
Reducing no-shows for community-based intakes depends on how people are initially engaged. Relationship building is always an important factor. Maintaining contact with the referral source and providing several prompts for the appointment to the client begins the process. Providing incentives to att...
What considerations do you take in starting stimulant medications for the management of adult ADHD?
Adult stimulant prescriptions for ADHD and The Journal of the American College of Cardiology in particular have published several articles in the last few years investigating the cardiovascular risk of long-term use of these medications. There have been three already in 2024 and data remains mixed.I...
How do you monitor patients who are symptomatically well-managed on clozapine with supratherapeutic drug levels?
I generally adhered to the published NIH guidelines (Correll et al., PMID 35759211). It also looks like we will be changing everything pretty soon as these recommendations will change.I still plan to do regular neutrophil and WBC counts, definitely not as frequently as previously recommended, but I ...
Do you believe that buspirone is ineffective in patients who are previously treated with benzodiazepines?
I've found buspirone helpful for patients who don't want to taper their benzo unless they have another medication on board. I wait until the buspirone is at a stable dose (typically at least 15 mg BID) before tapering the benzo. I specifically avoid cross-tapering/titration as I worry they will asso...