Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
How do you transition patients between different long-acting injectable antipsychotics?
When it is time for the next dose of LAI #1, administer LAI #2 instead. Use an equivalent dose to produce equivalent dopamine receptor activity. To determine the equivalent dose, consider the maximum recommended dose of #1 to be equivalent to the maximum recommended dose of #2. With all the sophisti...
What or where is the best reference guide for managing patients with bipolar disorder who are on meds and want to become pregnant?
Great question! There are a few resources that I find particularly helpful for both patients and providers. The MGH Center for Women's Mental Health Website, https://womensmentalhealth.org/, is a great resource for both patients and clinicians alike. There are speciality specific pages, including o...
What is your approach for managing persistent psychotic symptoms of a hallucinogen-induced persisting psychotic disorder?
There are two types of HPPD: type 1 (flashbacks only) and type 2, with the complex of visual symptoms elsewhere described. It seems to be due to disinhibition in visual processing in the occipital lobes. Interesting description here: The Mysteries of HPPD, both of which have demonstrable efficacy in...
What do you do if a patient with ADHD on dexamfetamine for many years develops Alzheimer's disease?
The issue with the diagnosis of ADHD is that adult-onset ADHD particularly, in my opinion, has major validity problems including a wide differential diagnosis, with no biomarkers. Also, it is now thought that Alzheimer's disease has a long prodrome (15-20 years) from being asymptomatic to having pro...
How do you approach antidepressant choices for patients with generalized anxiety disorder when the patient reports excessive sedation on low doses of SSRIs?
We forget that bupropion, despite systemic misconceptions, has a very good anxiolytic effect. It is the darling of the centers treating refractory anxiety disorders.
How do you approach the use of buprenorphine/naloxone in pregnant and breastfeeding patients?
If the patient is already on it, many doctors, including myself as an addiction psychiatrist, will simply switch to the same dose without the naloxone component, just to use the minimum necessary meds while pregnant. It’s not a hard and fast rule though. The dose may need titration later in pregnanc...
What are your perspectives on using GLP-1 agonists as a primary or adjunctive treatment in psychiatric care?
It does not appear that that class of medication could be a primary treatment option at the moment. There is a significant new and emerging body of information indicating that the use of these medications could be very useful and therapeutic potential is sizable. Given that the majority of our patie...
How frequently do you recommend EKGs in pediatric patients on antipsychotics, especially in patients taking antipsychotics with more QTc risk?
AACAP recommends baseline EKGs only in patients with a family history of cardiac problems (sudden cardiac death in young/arrhythmia in close relatives), personal or family history of arrhythmia/other cardiac abnormalities, personal history or symptoms including syncopal attacks, and palpitations to ...
What do you do when a patient experiences multiple rounds of antidepressant-related tachyphylaxis?
Our clinic is having remarkable success with TMS for those patients.
How do you manage MAT for opioid use disorder in lung transplant patients during the peri/postoperative period?
There is currently no evidence regarding mOUD in lung transplants. Available research represents generally a weak quality of evidence regarding opioid use for pain control before and after lung transplant. Non-opioid analgesic interventions, including thoracic epidural anesthesia and intercostal ner...