Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you manage fatty liver disease in patients on olanzapine who are reluctant to change meds?
I wonder if there are hepatologists available to consult with?There is a new drug with a novel mechanism of action Rezdiffra (resmetirom) that is specifically studied/designed for MASH (NASH). I haven't seen it used yet in my patients, but I am fascinated by the mechanism of action. Will it have psy...
When do you consider the use of clonidine in gabaergic withdrawal and how do you approach the risk of masking the autonomic signs of withdrawal when it is used?
There is limited and indirect evidence for the use of clonidine in "benzodiazepine-sparing" protocols for gabaergic withdrawal treatment. Generally, an anticonvulsant is used along with clonidine in this context. This "new" data recapitulates old, mainly European, studies combining beta-blockers wit...
How do you differentiate between hyperactive delirium and excited catatonia?
This is a highly complex distinction to make for several reasons, not the least of which is that the two conditions can coexist in the same patient at the same time. This has been demonstrated in some recent studies of mainly intensive care delirious patients, though the reported very high incidence...
What strategies have you found most effective for supporting weight loss in patients with bipolar disorder while minimizing the risk of mood destabilization?
If residual depressive symptoms are present, then the addition of bupropion is helpful. If the weight gain is deemed due to necessary psychiatric medication, then the addition of metformin often works. Of course, for the management of weight, diet and exercise need to be encouraged (in addition to t...
What medications would you consider for severe delusional disorder in a patient with RLS worsened by aripiprazole and quetiapine, who refuses clozapine?
Lyrica - better than gabapentin and will help with anxiety that might be brought on by delusional disorder. No FDA-approved medication for delusional disorder, and it may best be treated with gentle CBT for psychosis.
What alternative ADHD medications would you consider in a child with a complex cardiac history unresponsive to guanfacine?
Choosing another medication to treat ADHD in a child with a complex cardiac history who has already failed guanfacine is not a straightforward task. To make this decision, one would need to understand which symptoms of ADHD are causing the most functional impairment (inattention, hyperactivity, both...
How do you manage patients with severe, refractory schizophrenia or schizoaffective disorder who need complex pharmacologic regimens but consistently refuse labs and ECG monitoring?
Document that the risks and benefits of the refusal were discussed with the patient, have the patient sign the refusal document, and then treat the patient without the labs and EKGs.
What approach to antipsychotics do you take with patients with primary thought disorder who are now geriatric?
The primary goal is to manage psychotic symptoms effectively while minimizing adverse effects, particularly those that may exacerbate cognitive impairment. Older adults may experience altered pharmacokinetics and pharmacodynamics, which can affect the efficacy and safety of antipsychotic medication...
Do you use any alternative or non-FDA-approved treatments for smoking cessation?
For a non-medication, non-nicotine option, NADA auricular acupuncture has had some evidence-based success in tobacco cessation. It can also be somewhat helpful for anxiety and insomnia. The results are not always mind-blowing, but the risks are also not high so, in general, the outcome tends to be w...
What work up do you pursue for a thorough evaluation in patients that present with a potential diagnosis of dermatitis artefacta?
I have found dermatologic complaints some of the most challenging in my psychiatric practice. Dermatitis artefacta (DA) occurs when an individual produces self-inflicted skin lesions in order to assume the sick role, making it a type of factious disorder. When evaluating a patient with suspected DA,...