Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
What is your approach to augmenting treatment for depressive disorders in those continuing to take a tricyclic antidepressant at baseline due to historical effectiveness?
Depends on the risk of suicidality. If there is any history or any hint of a possibility of it, I do not continue with a TCA. I would augment with a dopamine agonist. I only use TCA to help with multiple comorbidities, such as migraines, insomnia, neuropathic pain, along with depression - knowing I ...
How do you evaluate and manage acute alcohol withdrawal when symptom-driven protocols are confounded/unreliable?
I developed a structured, objective approach centered on PAWSS risk stratification and standardized mMINDS plus RASS monitoring rather than relying solely on symptom-driven tools like CIWA. At intake, patients with suspected alcohol use disorder undergo PAWSS assessment, baseline mMINDS scoring, RAS...
How do you manage expectations around response time and durability of benefit in patients starting TMS?
Re: response time, I tell patients it is typical to not notice a lot of change in the first few weeks. Sometimes the clinician will observe brightening of affect earlier, but the patient him/herself often does not notice a whole lot. I use the 'going to the gym' analogy... a few days will not yield ...
When have you found hypnosis helpful for parasomnia?
Usually, when treating NREM parasomnias such as sleep terrors and sleepwalking, the patient has to practice the techniques every night in addition to removing identified triggers.
How do you approach patients with fibromyalgia who are reluctant to consider a psychiatric component to their illness but present with clear mood or anxiety symptoms?
Since patients with fibromyalgia (FM) are often stigmatized and worried that clinicians think “it is all in my head,” it is important to discuss FM treatment and mental health referral from a biopsychosocial perspective. This might include introducing concepts such as the pain/depression dyad, centr...
How do you counsel patients who want to understand why sublingual cyclobenzaprine works to relieve their fibromyalgia pain and other related symptoms?
I like to set the stage with patients and make sure they clearly understand the link between sleep disruption and pain sensitivity, particularly in the context of central pain and fibromyalgia. One of my rheumatology attendings during fellowship used to explain this using classic sleep research from...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
What is your approach to managing hallucinations in dementia?
One thing to remember is that hallucinations are not always disturbing to the patient, but to the caregiver! If the patient is fine with seeing a little girl or dog (often in LBD), the family just needs to be educated to let it go. They don’t need to AGREE that the hallucinations are present; they j...
What clinical factors guide your decision about if and when to restart antipsychotic medications in patients with primary psychotic disorders recovering from catatonia after stabilization with benzodiazepines or ECT?
The American Psychiatric Association's catatonia workgroup recently published an excellent Resource Document for Catatonia.In this document, they discuss some relevant points on pages 25 - 27: There is a longstanding history of using antipsychotics in catatonia, with available reports on the use of ...
How are you thinking about incorporating mirtazapine into your treatment approach for patients with methamphetamine use disorder?
In my experience as an addiction psychiatrist in Maryland, I always found mirtazapine to be a low-hanging fruit in my "dual diagnosis" patients, re: reasonably quickly helping with insomnia and poor appetite that comes with drug use or especially opioid withdrawal. Also comes with the potential plus...