Psychiatry
Expert discussions on psychopharmacology, behavioral health interventions, and psychiatric care approaches.
Recent Discussions
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...
Other than firearms, what dangerous items do you recommend removing or securing as a part of safety planning?
medications including OTC sharps, including knives in the kitchen (this will be tough for the family - I have had them remove from drawers and keep one secure for use until the acuity resolves) cleaners (all bathroom/kitchen cleaners) alcohol
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...
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 REM behavior disorder not adequately treated with melatonin and clonazepam?
If both are at their max doses, then, in addition to making sure the bedroom environment is safe, I recommend rivastigmine. HA
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...
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...
What is your approach to initiating naltrexone in patients with alcohol use disorder and co-occurring liver disease?
In patients with AUD and co-occurring liver disease, I think the hepatotoxicity concerns around naltrexone have historically been overstated relative to both the actual evidence and the hepatic risk of ongoing alcohol exposure itself. The original 1980s data that triggered the FDA hepatotoxicity war...