Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you counsel patients/give data on long-term use of second generation antipsychotics and risk of involuntary movement disorders?
I never try to use SGA as an adjunct for MDD augmentation - if anything, it might be Caplyta (recently FDA approved and lower side effect profile). I have seen tardive dyskinesia from 1 year of Abilify with Zoloft from a PCP. So I am very hesitant to start an antipsychotic as an adjunct. But at the ...
When do you order brain imaging in young adults presenting with first-episode psychosis in the absence of clear neurologic red flags?
You should always consider brain imaging, at least at CT, in the first episode of psychosis. While this will be negative almost 99% of the time, it's always good to rule out that population that may have something else going on in the brain that we can actually attribute the psychosis to. Also, chec...
Is there a role for use of GLP-1/GIP receptor agonists in the management of substance use disorders, whether or not they meet other inclusion criteria for their use?
Currently, we lack the RCTs to understand the full impact of GLP-1s on SUD outcomes. Most evidence is pre-clinical, observational, suggesting potential reductions in cravings and alcohol use. A recent RCT, lab study of semaglutide in non-treatment-seeking adults with AUD showed decreased alcohol con...
How do you counsel patients who are interested in using kratom for chronic pain management?
I am not a pain management expert, but would recommend against use for chronic pain management. Risks outweigh in a significant order. It's not FDA-approved for any form of pain treatment. There is no dosage reference to use. The pain control one gets may be too low compared to the addictive risks, ...
For pediatric patients who are being successfully treated for migraines with a TCA such as amitriptyline, would you consider starting an additional SSRI or SNRI for mood/anxiety symptoms, given the risk of serotonin syndrome?
My first inclination would be to just increase the TCA that is already being used and bring it up to therapeutic levels for antidepressant and anxiolytic effects. The TCAs are very effective antidepressants but come with a wider array of side effects, which makes compliance a bigger issue with these...
What strategies have you found effective in improving acceptance of long-acting injectable antipsychotics in patients with serious mental illness who are ambivalent about treatment?
Good question. I think it's important to understand the patient's perspective, because everyone can have a unique fear regarding LAIs. It could be that they have a fear of needles, are concerned about a lack of autonomy, or are worried about the mechanism of action and potential adverse events. You ...
How would you treat psychotic symptoms in a patient with atypical psychotic-induced leukopenia with absolute neutrophil count (ANC) below 500 cells/µL (<0.5 x 10^9 L)?
I have not been faced with that situation except on Clozaril. I will use benzodiazepines initially to control anxiety and reduce the stress with psychotic symptoms. Later, when the white count starts to improve, I will initiate a different drug. Will go slow and check counts often enough not to miss...
What is your approach to using prazosin to treat day-time symptoms in PTSD?
I will only use prazosin during the day if the patient is using it for sleep disturbance/nightmares. If they are not using prazosin, then I prefer guanfacine during the day. If using prazosin, I start at 0.5 mg in the morning and then BID. I will titrate up based on reaction and side effects.
How do you approach continued prescribing of benzodiazepines when a patient who is already prescribed benzodiazepines reports concurrent illicit benzodiazepine use?
The management of patients who are prescribed benzodiazepines while concurrently using illicit benzodiazepines has become increasingly complex, particularly with the growing prevalence of synthetic benzodiazepine analogs within the illicit drug supply. Over the past decade, benzodiazepine prescribin...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...