Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
Which cognitive screening tools do you use when evaluating older adults with suspected dementia?
In keeping with Alexander Luria's (paraphrased) maxim that knowing what a patient gets wrong on cognitive screening is incomplete until you know why/how they erred, I'd say the tool used is less important than interpreting it. So, I don't worry too much about MMSE vs MoCA vs SLUMS (as long as the MM...
What opportunities do you see for combining xanomeline-tropsium (Cobenfy) with other anti-psychotic agents?
The opportunities of combining Cobenfy with any of our other antipsychotic treatments, in my opinion, are unlimited. This is one of the most important aspects of its drug use that has NOT been systematically tested. One might think first of combining Cobenfy with a widely used drug, like risperidone...
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...
In children with unknown family cardiac history, do you require a routine EKG prior to starting a stimulant?
The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) have stated that ADHD medications have not been shown to cause heart conditions or sudden cardiac death, although stimulant medications do increase heart rate and blood pressure. By increasing sympathetic nervous syste...
When, if ever, do you consider using dronabinol to treat agitation in dementia?
Dronabinol should be considered for treating agitation in dementia when non-pharmacological interventions and standard pharmacological options, such as antidepressants or antipsychotics, have failed or are poorly tolerated. I have a handful of patients in my practice who fit that scenario and benefi...
What are the most effective strategies for managing weight gain associated with antipsychotic medications?
In my experience, the following things have worked. Reassurance that it is a medication side-effect. Consider switching the anti-psychotic (or at least try and decrease the dose of the antipsychotic). Aripiprazole, Caplyta (Lumateperone), and Vraylar (Cariprazine) have shown benefits vis a vis weig...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
How do you differentiate major depressive disorder from baseline functioning in patients with intellectual disabilities?
A general assumption of psychiatry is that people with intellectual disabilities can be afflicted with nearly any of the psychiatric disorders apparent in the general population. However, making the diagnosis of other psychiatric disorders in people with varying degrees of intellectual disability an...
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...
When do you refer a patient with difficult-to-treat depression for esketamine nasal spray versus IV ketamine treatment?
For treatment-resistant depression (TRD), intravenous ketamine is slightly more efficacious than intranasal esketamine (Spravato), probably due to more controlled bioavailability (all the substance administered is absorbed) and better personalization of doses. However, IV ketamine is usually not cov...