Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you adjust antipsychotic treatment during pregnancy?
Thank you for the question. In general, I try to make as few medication changes during pregnancy as possible, and try to ensure that patients are relatively stable from a psychiatric perspective for several months before conception. Obviously, this is not always feasible. If a patient needs introduc...
How do you treat TBI-associated aggression?
Propranolol has the best evidence, but you can also consider Depakote (since there is an increased risk of seizure as well) or an atypical antipsychotic. Fleminger et al., PMID 17054165 Williamson et al., PMID 31289093 Khalili et al., PMID 32002583
How do you decide between initiating antidepressants vs. hormone replacement therapy for post-menopausal depression?
I think the most logical answer to this is to treat what is deficient. The Women's Health Initiative Study and the following media reports on it were one of the most damaging OB/GYN and psychiatric mishaps in recent history, scaring half of women off of their HRT in a 6-month period. For some reason...
How do you decide between using immediate-release versus long-acting lithium?
In general, long-acting (i.e., controlled release) lithium is thought to cause less nausea and other common side effects (like tremors) than IR formulations but has also been associated with higher rates of diarrhea due to differences in absorption. Another consideration may be the dose you are try...
When do you choose to switch to antidepressants vs augmentation in treatment-resistant depression?
When I approach depression that has been resistant to many antidepressant trials, I consider the following: First, I reassess the diagnosis. This includes considering comorbidities such as menopause symptoms, ED symptoms, exacerbation of chronic medical issues, and onset of MNCD. I ensure I have con...
What is your approach in counseling a patient with delusions of parasitosis?
Delusions of parasitosis (DOP) or delusions of infestation (DOI) are among the most challenging conditions we treat as dermatologists. I am not sure there is one approach to treating these patients and it can often feel very frustrating and unsatisfying. Nonetheless, we all will encounter these pati...
What is the best treatment option for a patient with bipolar disorder, who stopped her medication at the start of pregnancy and is now at the end of 2nd trimester?
This is a great question. Restarting medication would be a top priority, as we know that the risk of relapse for bipolar disorder mood episodes in women is at least as common during pregnancy as in the non-pregnant state, and that discontinuation of medications increases the risk of relapse during p...
Would you recommend CRRT instead of intermittent hemodialysis to prevent lithium rebound in a patient with lithium toxicity after an initial intermittent hemodialysis session?
I think the best way to approach any "overdose" of a drug that is dialyzable and may have a rebound is to start with hemodialysis and run it until you have achieved your desired response (drug level, improvement in some other parameter) and follow that with CRRT to manage any rebound. This is well s...
How do you approach deprescribing psychiatric medications in elderly patients with polypharmacy concerns?
Briefly, I take 6 steps in my mind to tackle this carefully. Is prescribing really necessary? Can they try non-pharmacological management first? Carefully review the medical, surgical, and social history to avoid possible complications. Thorough medication reconciliation (including OTCs, herbals, ...
When do you consider attributing isolated psychosis to an acute ischemic stroke?
Though relatively rare, systematic reviews have found post-stroke psychosis to occur in just under 5% of patients. When considering attributing psychosis to an acute stroke, there are several things it can be helpful to consider: Differential diagnosis: Making sure to rule out more common etio...